25
Price Schedule BEHIND THE EAR TYPES - The total price shall be for a single hearing aid or two hearing aids and appropriate case. List model numbers/name and full range of the instrument has a T-coil or T-coil capability. For digital aids, indicate whether a remote control is required. For conventional aids, indicate whether it is a linear or compression circuit L = Linear, C = Compression. DESCRIPTION & FEATURES (See below) db RANGE MANUFA CTURER MODEL NUMBER (19 Characters or less) HCPCS CODE(S) EQUIPMENT PUBLISHED LIST PRICE EQUIPMENT PERCENT DISCOUNT OFF LIST PRICE EQUIPMENT TOTAL PRICE FIXED NON - WARRANTY REPAIR PRICE NON - WARRANTY REPAIR PERIOD (MONTHS) WARRANTY REPAIR PERIOD (MONTHS) Audeo M70-312 Phonak 050-0493-H0 V5257 Monaural $1,649.00 54.579% $749.00 $129.00 12 36 67 dB Max Gain/130 dB Max Output V5261 Binaural $3,298.00 54.579% $1,498.00 $258.00 12 36 Audeo M50-312 Phonak 050-0492-H0 V5257 Monaural $1,099.00 60.055% $439.00 $129.00 12 36 67 dB Max Gain/130 dB Max Output V5261 Binaural $2,198.00 60.055% $878.00 $258.00 12 36 Audeo M30-312 Phonak 050-0491-H0 V5257 Monaural $749.00 53.004% $352.00 $129.00 12 36 67 dB Max Gain/130 dB Max Output V5261 Binaural $1,498.00 53.004% $704.00 $258.00 12 36 Audeo M70-312T Phonak 050-0497-H0 V5257 Monaural $1,699.00 55.915% $749.00 $129.00 12 36 67 dB Max Gain/130 dB Max Output V5261 Binaural $3,398.00 55.915% $1,498.00 $258.00 12 36 Audeo M50-312T Phonak 050-0496-H0 V5257 Monaural $1,149.00 61.793% $439.00 $129.00 12 36 67 dB Max Gain/130 dB Max Output V5261 Binaural $2,298.00 61.793% $878.00 $258.00 12 36 Audeo M30-312T Phonak 050-0495-H0 V5257 Monaural $799.00 55.945% $352.00 $129.00 12 36 67 dB Max Gain/130 dB Max Output V5261 Binaural $1,598.00 55.945% $704.00 $258.00 12 36 Audeo M70-13T Phonak 050-0518-H0 V5257 Monaural $1,699.00 55.915% $749.00 $129.00 12 36 XXdB Max Gain/1XX dB Max Output V5261 Binaural $3,398.00 55.915% $1,498.00 $258.00 12 36 Audeo M50-13T Phonak 050-0517-H0 V5257 Monaural $1,149.00 61.793% $439.00 $129.00 12 36 67 dB Max Gain/130 dB Max Output V5261 Binaural $2,298.00 61.793% $878.00 $258.00 12 36 Audeo M30-13T Phonak 050-0516-H0 V5257 Monaural $799.00 55.945% $352.00 $129.00 12 36 67 dB Max Gain/130 dB Max Output V5261 Binaural $1,598.00 55.945% $704.00 $258.00 12 36 Digital RIC - programmable 16 channels/6 programs. Includes AutoSense OS 3.0 - SoundRecover2 - DuoPhone - Speech in 360 - QuickSync - WhistleBlock - NoiseBlock - Speech in Loud Noise - WindBlock - Sound Relax - Real Ear Sound - WaterResistant - Datalogging - Tinnitus Balance - RogerDirect - Size 312 Battery. Mild/Moderate/Severe hearing loss Digital RIC - programmable 12 channels/6 programs. Includes AutoSense OS 3.0 - SoundRecover2 - DuoPhone - QuickSync - WhistleBlock - NoiseBlock - Real Ear Sound - WaterResistant - Datalogging - Tinnitus Balance - RogerDirect - Size 312 Battery. Mild/Moderate/Severe hearing loss Digital RIC - programmable 8 channels/6 programs. Includes AutoSense OS 3.0 - SoundRecover2 - QuickSync - WhistleBlock - NoiseBlock - WaterResistant - Datalogging - Tinnitus Balance - RogerDirect - Size 312 Battery. Mild/Moderate/Severe hearing loss Digital RIC - programmable 16 channels/6 programs, Telecoil. Includes AutoSense OS 3.0 - SoundRecover2 - DuoPhone - Speech in 360 - QuickSync - WhistleBlock - NoiseBlock - Speech in Loud Noise - WindBlock - Sound Relax - Real Ear Sound - WaterResistant - Datalogging - Tinnitus Balance - RogerDirect - Size 312 Battery. Mild/Moderate/Severe hearing loss Digital RIC - programmable 12 channels/6 programs, Telecoil. Includes AutoSense OS 3.0 - SoundRecover2 - DuoPhone - QuickSync - WhistleBlock - NoiseBlock - Real Ear Sound - WaterResistant - Datalogging - Tinnitus Balance - RogerDirect - Size 312 Battery. Mild/Moderate/Severe hearing loss Digital RIC - programmable 8 channels/6 programs, Telecoil. Includes AutoSense OS 3.0 - SoundRecover2 - QuickSync - WhistleBlock - NoiseBlock - WaterResistant - Datalogging - Tinnitus Balance - RogerDirect - Size 312 Battery. Mild/Moderate/Severe hearing loss Digital RIC - programmable 16 channels/6 programs, Telecoil. Includes AutoSense OS 3.0 - SoundRecover2 - DuoPhone - Speech in 360 - QuickSync - WhistleBlock - NoiseBlock - Speech in Loud Noise - WindBlock - Sound Relax - Real Ear Sound - WaterResistant - Datalogging - Tinnitus Balance - RogerDirect - Size 13 Battery. Mild/Moderate/Severe hearing loss Digital RIC - programmable 12 channels/6 programs, Telecoil. Includes AutoSense OS 3.0 - SoundRecover2 - DuoPhone - QuickSync - WhistleBlock - NoiseBlock - Real Ear Sound - WaterResistant - Datalogging - Tinnitus Balance - RogerDirect - Size 13 Battery. Mild/Moderate/Severe hearing loss Digital RIC - programmable 8 channels/6 programs, Telecoil. Includes AutoSense OS 3.0 - SoundRecover2 - QuickSync - WhistleBlock - NoiseBlock - WaterResistant - Datalogging - Tinnitus Balance - RogerDirect - Size 13 Battery. Mild/Moderate/Severe hearing loss Exhibit A - Sonova Phonak - Contract No. 129975 Amendment No. 4 1 of 25

EQUIPMENT EQUIPMENT PERCENT FIXED NON - …...XXdB Max Gain/1XX dB Max Output V5261 Binaural $3,398.00 55.915% $1,498.00 $258.00 12 36 Audeo M50-13T Phonak 050-0517-H0 V5257 Monaural

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Page 1: EQUIPMENT EQUIPMENT PERCENT FIXED NON - …...XXdB Max Gain/1XX dB Max Output V5261 Binaural $3,398.00 55.915% $1,498.00 $258.00 12 36 Audeo M50-13T Phonak 050-0517-H0 V5257 Monaural

Price Schedule

BEHIND THE EAR TYPES - The total price shall be for a single hearing aid or two hearing aids and appropriate case. List model numbers/name and full range of the instrument has a T-coil or T-coil capability. For digital aids, indicate whether a remote control is required. For conventional aids, indicate whether it is a linear or compression circuit L = Linear, C = Compression.

DESCRIPTION & FEATURES (See below) db RANGEMANUFA

CTURER

MODEL NUMBER (19

Characters or less)HCPCS CODE(S)

EQUIPMENT

PUBLISHED

LIST PRICE

EQUIPMENT PERCENT

DISCOUNT OFF LIST

PRICE

EQUIPMENT TOTAL

PRICE

FIXED NON -

WARRANTY REPAIR

PRICE

NON - WARRANTY

REPAIR PERIOD

(MONTHS)

WARRANTY REPAIR PERIOD

(MONTHS)

Audeo M70-312 Phonak 050-0493-H0 V5257 Monaural $1,649.00 54.579% $749.00 $129.00 12 36

67 dB Max Gain/130

dB Max Output V5261 Binaural $3,298.00 54.579% $1,498.00 $258.00 12 36

Audeo M50-312 Phonak 050-0492-H0V5257 Monaural $1,099.00 60.055% $439.00 $129.00 12 36

67 dB Max Gain/130

dB Max Output V5261 Binaural $2,198.00 60.055% $878.00 $258.00 12 36

Audeo M30-312 Phonak 050-0491-H0V5257 Monaural $749.00 53.004% $352.00 $129.00 12 36

67 dB Max Gain/130

dB Max Output V5261 Binaural $1,498.00 53.004% $704.00 $258.00 12 36

Audeo M70-312T Phonak 050-0497-H0V5257 Monaural $1,699.00 55.915% $749.00 $129.00 12 36

67 dB Max Gain/130

dB Max Output V5261 Binaural $3,398.00 55.915% $1,498.00 $258.00 12 36

Audeo M50-312T Phonak 050-0496-H0V5257 Monaural $1,149.00 61.793% $439.00 $129.00 12 36

67 dB Max Gain/130

dB Max Output V5261 Binaural $2,298.00 61.793% $878.00 $258.00 12 36

Audeo M30-312T Phonak 050-0495-H0 V5257 Monaural $799.00 55.945% $352.00 $129.00 12 36

67 dB Max Gain/130

dB Max Output V5261 Binaural $1,598.00 55.945% $704.00 $258.00 12 36

Audeo M70-13T Phonak 050-0518-H0V5257 Monaural $1,699.00 55.915% $749.00 $129.00 12 36

XXdB Max Gain/1XX

dB Max Output V5261 Binaural $3,398.00 55.915% $1,498.00 $258.00 12 36

Audeo M50-13T Phonak 050-0517-H0V5257 Monaural $1,149.00 61.793% $439.00 $129.00 12 36

67 dB Max Gain/130

dB Max Output V5261 Binaural $2,298.00 61.793% $878.00 $258.00 12 36

Audeo M30-13T Phonak 050-0516-H0 V5257 Monaural $799.00 55.945% $352.00 $129.00 12 36

67 dB Max Gain/130

dB Max Output V5261 Binaural $1,598.00 55.945% $704.00 $258.00 12 36

Digital RIC - programmable 16 channels/6 programs. Includes

AutoSense OS 3.0 - SoundRecover2 - DuoPhone - Speech in 360 -

QuickSync - WhistleBlock - NoiseBlock - Speech in Loud Noise -

WindBlock - Sound Relax - Real Ear Sound - WaterResistant -

Datalogging - Tinnitus Balance - RogerDirect - Size 312 Battery.

Mild/Moderate/Severe hearing loss

Digital RIC - programmable 12 channels/6 programs. Includes

AutoSense OS 3.0 - SoundRecover2 - DuoPhone - QuickSync -

WhistleBlock - NoiseBlock - Real Ear Sound - WaterResistant -

Datalogging - Tinnitus Balance - RogerDirect - Size 312 Battery.

Mild/Moderate/Severe hearing loss

Digital RIC - programmable 8 channels/6 programs. Includes

AutoSense OS 3.0 - SoundRecover2 - QuickSync - WhistleBlock -

NoiseBlock - WaterResistant - Datalogging - Tinnitus Balance -

RogerDirect - Size 312 Battery. Mild/Moderate/Severe hearing loss

Digital RIC - programmable 16 channels/6 programs, Telecoil.

Includes AutoSense OS 3.0 - SoundRecover2 - DuoPhone - Speech

in 360 - QuickSync - WhistleBlock - NoiseBlock - Speech in Loud

Noise - WindBlock - Sound Relax - Real Ear Sound - WaterResistant

- Datalogging - Tinnitus Balance - RogerDirect - Size 312 Battery.

Mild/Moderate/Severe hearing loss

Digital RIC - programmable 12 channels/6 programs, Telecoil.

Includes AutoSense OS 3.0 - SoundRecover2 - DuoPhone -

QuickSync - WhistleBlock - NoiseBlock - Real Ear Sound -

WaterResistant - Datalogging - Tinnitus Balance - RogerDirect - Size

312 Battery. Mild/Moderate/Severe hearing loss

Digital RIC - programmable 8 channels/6 programs, Telecoil.

Includes AutoSense OS 3.0 - SoundRecover2 - QuickSync -

WhistleBlock - NoiseBlock - WaterResistant - Datalogging - Tinnitus

Balance - RogerDirect - Size 312 Battery. Mild/Moderate/Severe

hearing loss

Digital RIC - programmable 16 channels/6 programs, Telecoil.

Includes AutoSense OS 3.0 - SoundRecover2 - DuoPhone - Speech

in 360 - QuickSync - WhistleBlock - NoiseBlock - Speech in Loud

Noise - WindBlock - Sound Relax - Real Ear Sound - WaterResistant

- Datalogging - Tinnitus Balance - RogerDirect - Size 13 Battery.

Mild/Moderate/Severe hearing loss

Digital RIC - programmable 12 channels/6 programs, Telecoil.

Includes AutoSense OS 3.0 - SoundRecover2 - DuoPhone -

QuickSync - WhistleBlock - NoiseBlock - Real Ear Sound -

WaterResistant - Datalogging - Tinnitus Balance - RogerDirect - Size

13 Battery. Mild/Moderate/Severe hearing loss

Digital RIC - programmable 8 channels/6 programs, Telecoil.

Includes AutoSense OS 3.0 - SoundRecover2 - QuickSync -

WhistleBlock - NoiseBlock - WaterResistant - Datalogging - Tinnitus

Balance - RogerDirect - Size 13 Battery. Mild/Moderate/Severe

hearing loss

Exhibit A - Sonova Phonak - Contract No. 129975 Amendment No. 4 1 of 25

Page 2: EQUIPMENT EQUIPMENT PERCENT FIXED NON - …...XXdB Max Gain/1XX dB Max Output V5261 Binaural $3,398.00 55.915% $1,498.00 $258.00 12 36 Audeo M50-13T Phonak 050-0517-H0 V5257 Monaural

Price Schedule

DESCRIPTION & FEATURES (See below) db RANGEMANUFA

CTURER

MODEL NUMBER (19

Characters or less)HCPCS CODE(S)

EQUIPMENT

PUBLISHED

LIST PRICE

EQUIPMENT PERCENT

DISCOUNT OFF LIST

PRICE

EQUIPMENT TOTAL

PRICE

FIXED NON -

WARRANTY REPAIR

PRICE

NON - WARRANTY

REPAIR PERIOD

(MONTHS)

WARRANTY REPAIR PERIOD

(MONTHS)

Audeo M70-R Rechargeable (includes charger case) Phonak 050-0485-H0V5257 Monaural $1,749.00 55.746% $774.00 $129.00 12 36

67 dB Max Gain/130

dB Max Output V5261 Binaural $3,498.00 55.746% $1,548.00 $258.00 12 36

Audeo M50-R Rechargeable (includes charger case) Phonak 050-0440-H0 V5257 Monaural $1,199.00 62.469% $450.00 $129.00 12 36

67 dB Max Gain/130

dB Max Output V5261 Binaural $2,398.00 62.469% $900.00 $258.00 12 36

Audeo M30-R Rechargeable (includes charger case) Phonak 050-0439-H0 V5257 Monaural $849.00 55.595% $377.00 $129.00 12 36

67 dB Max Gain/130

dB Max Output V5261 Binaural $1,698.00 55.595% $754.00 $258.00 12 36

Audeo M70-RT Rechargeable (includes charger case) Phonak 050-0489-H0V5257 Monaural $1,799.00 56.976% $774.00 $129.00 12 36

67 dB Max Gain/130

dB Max Output V5261 Binaural $3,598.00 56.976% $1,548.00 $258.00 12 36

Audeo M50-RT Rechargeable (includes charger case) Phonak 050-0488-H0 V5257 Monaural $1,249.00 63.971% $450.00 $129.00 12 36

67 dB Max Gain/130

dB Max Output V5261 Binaural $2,498.00 63.971% $900.00 $258.00 12 36

Audeo M30-RT Rechargeable (includes charger case) Phonak 050-0487-H0 V5257 Monaural $899.00 58.065% $377.00 $129.00 12 36

67 dB Max Gain/130

dB Max Output V5261 Binaural $1,798.00 58.065% $754.00 $258.00 12 36

Sky M70-M Phonak 050-0647-H0 V5257 Monaural $1,649.00 54.579% $749.00 $129.00 12 36

68 dB Max Gain/134

dB Max Output V5261 Binaural $3,298.00 54.579% $1,498.00 $258.00 12 36

Sky M50-M Phonak 050-0635-H0V5257 Monaural $1,099.00 64.968% $385.00 $129.00 12 36

68 dB Max Gain/134

dB Max Output V5261 Binaural $2,198.00 64.968% $770.00 $258.00 12 36

Digital RIC - programmable 16 channels/6 programs. Includes

AutoSense OS 3.0 - SoundRecover2 - DuoPhone - Speech in 360 -

QuickSync - WhistleBlock - NoiseBlock - Speech in Loud Noise -

WindBlock - Sound Relax - Real Ear Sound - WaterResistant -

Datalogging - Tinnitus Balance - RogerDirect - Rechargeable

Battery. Mild/Moderate/Severe hearing loss

Digital RIC - programmable 12 channels/6 programs. Includes

AutoSense OS 3.0 - SoundRecover2 - DuoPhone - QuickSync -

WhistleBlock - NoiseBlock - Real Ear Sound - WaterResistant -

Datalogging - Tinnitus Balance - RogerDirect - Rechargeable Battery.

Mild/Moderate/Severe hearing loss

Digital RIC - programmable 8 channels/6 programs. Includes

AutoSense OS 3.0 - SoundRecover2 - QuickSync - WhistleBlock -

NoiseBlock - WaterResistant - Datalogging - Tinnitus Balance -

RogerDirect - Rechargeable Battery. Mild/Moderate/Severe hearing

loss

Digital RIC - programmable 16 channels/6 programs, Telecoil.

Includes AutoSense OS 3.0 - SoundRecover2 - DuoPhone - Speech

in 360 - QuickSync - WhistleBlock - NoiseBlock - Speech in Loud

Noise - WindBlock - Sound Relax - Real Ear Sound - WaterResistant

- Datalogging - Tinnitus Balance - RogerDirect - Rechargeable

Battery. Mild/Moderate/Severe hearing loss

Digital RIC - programmable 12 channels/6 programs, Telecoil.

Includes AutoSense OS 3.0 - SoundRecover2 - DuoPhone -

QuickSync - WhistleBlock - NoiseBlock - Real Ear Sound -

WaterResistant - Datalogging - Tinnitus Balance - RogerDirect -

Rechargeable Battery. Mild/Moderate/Severe hearing loss

Digital RIC - programmable 8 channels/6 programs, Telecoil.

Includes AutoSense OS 3.0 - SoundRecover2 - QuickSync -

WhistleBlock - NoiseBlock - WaterResistant - Datalogging - Tinnitus

Balance - RogerDirect - Rechargeable Battery.

Mild/Moderate/Severe hearing loss

Pediatric Digital BTE - programmable 16 channels/6 programs.

Includes AutoSense Sky OS 3.0 - SoundRecover2 - DuoPhone -

Speech in 360 -QuickSync - Indicator Light - TamperProof Battery

Door - Tamper Proof mini ear hook - WhistleBlock - NoiseBlock -

Real Ear Sound - Speech in Loud Noise - WindBlock - Sound Relax -

WaterResistant - Datalogging - RogerDirect - Tinnitus Balance - Size

312 Battery. Mild/Moderate/Severe hearing loss

Pediatric Digital BTE - programmable 12 channels/6 programs.

Includes AutoSense Sky OS 3.0 - SoundRecover2 - DuoPhone -

QuickSync - Indicator Light - TamperProof Battery Door - Tamper

Proof mini ear hook - WhistleBlock - NoiseBlock - Real Ear Sound -

WaterResistant - Datalogging - Tinnitus Balance - RogerDirect - Size

312 Battery. Mild/Moderate/Severe hearing loss

Exhibit A - Sonova Phonak - Contract No. 129975 Amendment No. 4 2 of 25

Page 3: EQUIPMENT EQUIPMENT PERCENT FIXED NON - …...XXdB Max Gain/1XX dB Max Output V5261 Binaural $3,398.00 55.915% $1,498.00 $258.00 12 36 Audeo M50-13T Phonak 050-0517-H0 V5257 Monaural

Price Schedule

DESCRIPTION & FEATURES (See below) db RANGEMANUFA

CTURER

MODEL NUMBER (19

Characters or less)HCPCS CODE(S)

EQUIPMENT

PUBLISHED

LIST PRICE

EQUIPMENT PERCENT

DISCOUNT OFF LIST

PRICE

EQUIPMENT TOTAL

PRICE

FIXED NON -

WARRANTY REPAIR

PRICE

NON - WARRANTY

REPAIR PERIOD

(MONTHS)

WARRANTY REPAIR PERIOD

(MONTHS)

Bolero M70-M Phonak 050-0534-H0V5257 Monaural $1,649.00 54.579% $749.00 $129.00 12 36

68 dB Max Gain/134

dB Max Output V5261 Binaural $3,298.00 54.579% $1,498.00 $258.00 12 36

Bolero M50-M Phonak 050-0533-H0 V5257 Monaural $1,099.00 60.055% $439.00 $129.00 12 36

68 dB Max Gain/134

dB Max Output V5261 Binaural $2,198.00 60.055% $878.00 $258.00 12 36

Bolero M30-M Phonak 050-0532-H0V5257 Monaural $749.00 53.004% $352.00 $129.00 12 36

68 dB Max Gain/134

dB Max Output V5261 Binaural $1,498.00 53.004% $704.00 $258.00 12 36

Sky B70-M Phonak 050-0464-01V5257 Monaural $1,399.00 50.036% $699.00 $129.00 12 36

68dB Max Gain/134

dB Max Output V5261 Binaural $2,798.00 50.036% $1,398.00 $258.00 12 36

Sky B70-P Phonak 050-0468-01 V5257 Monaural $1,399.00 50.036% $699.00 $129.00 12 36

71dB Max Gain/135

dB Max Output V5261 Binaural $2,798.00 50.036% $1,398.00 $258.00 12 36

Sky B70-SP Phonak 050-0472-01 V5257 Monaural $1,399.00 50.036% $699.00 $129.00 12 36

83dB Max Gain/143

dB Max Output V5261 Binaural $2,798.00 50.036% $1,398.00 $258.00 12 36

Sky B70-UP Phonak 050-0476-01V5257 Monaural $1,399.00 50.036% $699.00 $129.00 12 36

85dB Max Gain/145

dB Max Output V5261 Binaural $2,798.00 50.036% $1,398.00 $258.00 12 36

Sky B70-RIC Phonak 050-0480-01 V5257 Monaural $1,399.00 50.036% $699.00 $129.00 12 36

72dB Max Gain/136

dB Max Output V5261 Binaural $2,798.00 50.036% $1,398.00 $258.00 12 36

Sky B70-PR Rechargeable (includes charger case) Phonak 050-0483-01V5257 Monaural $1,649.00 56.095% $724.00 $129.00 12 36

71dB Max Gain/135

dB Max OutputV5261 Binaural $3,298.00 56.095% $1,448.00 $258.00 12

36

Digital BTE - programmable 8 channels/6 programs. Includes

AutoSense OS 3.0 - SoundRecover2 - QuickSync - WhistleBlock -

NoiseBlock - WaterResistant - Datalogging - Tinnitus Balance -

RogerDirect - Size 312 Battery. Mild/Moderate/Severe hearing loss

Digital BTE - programmable 16 channels/6 programs. Includes

AutoSense OS 3.0 - SoundRecover2 - DuoPhone - Speech in 360 -

QuickSync - WhistleBlock - NoiseBlock - Real Ear Sound - Speech in

Loud Noise - WindBlock - Sound Relax - WaterResistant -

Datalogging - Tinnitus Balance - RogerDirect - Size 312 Battery.

Mild/Moderate/Severe hearing loss

Digital BTE - programmable 12 channels/6 programs. Includes

AutoSense OS 3.0 - SoundRecover2 - DuoPhone - QuickSync -

WhistleBlock - NoiseBlock - Real Ear Sound - WaterResistant -

Datalogging - Tinnitus Balance - RogerDirect - Size 312 Battery.

Mild/Moderate/Severe hearing loss

Pediatric Digital RIC - programmable 16 channels/7 programs.

Includes SoundRecover2 - UltraZoom Advanced-QuickSync -

WhistleBlock - NoiseBlock - Flex Volume - Zoom Control -

UserPreference - Tinnitus Balance- WindBlock WaterResistant -

Datalogging - DuoPhone - FM/DAI - Cros/BiCros compatibility - T-

Coil - Size13 Battery. Moderate/Severe hearing loss

Pediatric Digital BTE - programmable 16 channels/7 programs.

Includes AutoSense Sky OS-SoundRecover2 -DuoPhone- UltraZoom

Advanced-QuickSync Indicator Light-TamperProof Battery Door-

Tamper Proof mini ear hook - WhistleBlock - NoiseBlock - Flex

Control - Zoom Control - UserPreference -Duo Phone- WindBlock-

Sound Relax- Roger Ready-WaterResistant - Datalogging - FM/DAI -

Cros/BiCros compatibility - T-Coil -RogerMy Link- Size312 Battery.

Moderate/Severe hearing loss

Pediatric Digital BTE - programmable 16 channels/7 programs.

Includes AutoSense Sky OS-SoundRecover2 - DuoPhone-Roger

Ready-Indicator Light-Tamper Proof Battery Door-Tamper Proof Ear

Hook-UltraZoom Advanced-QuickSync - WhistleBlock - NoiseBlock -

Flex Control - UserPreference - Tinnitus Balance- WindBlock-Sound

Relax- WaterResistant - Datalogging - DuoPhone - FM/DAI -

Cros/BiCros compatibility - T-Coil -Roger My Link- Size 13 Battery.

Moderate/Severe hearing loss

Pediatric Digital Power BTE - programmable 16 channels/7

programs. Includes AutoSense Sky OS-SoundRecover2 - UltraZoom

Advanced-QuickSync - WhistleBlock - NoiseBlock - Flex Control -

Zoom Control - UserPreference - Tinnitus Balance-Duo Phone-

WindBlock-Sound Relax- WaterResistant - Datalogging - FM/DAI -

Cros/BiCros compatibility - T-Coil -RogerMy Link-Indicator Light-

Tamperproof Battery Door-Tamperproof Mini ear hook - Size312

Battery. Moderate/Severe hearing loss

Pediatric Super Power Digital BTE - programmable 12 channels/4

programs. Includes AutoSense Sky OS-SoundRecover2 - UltraZoom -

QuickSync - WhistleBlock - NoiseBlock - Tinnitus Balance - Indicator

Light-TamperProof Battery Door-Tamper Proof mini ear hook -

WaterResistant - Datalogging - EasyPhone - FM/DAI - Cros/BiCros

compatibility - Size 675 Battery. Moderate/Severe hearing loss

Digital BTE - programmable 16 channels/4 Programs. Includes

SoundRecover2-Sound Relax-WindBlock-NoiseBlock-WhistleBlock-

TCoil/Roger MyLink-Roger(ComPIlotII/Roger X) - Speech in 360 -

Speech in Loud Noise - DuoPhone- Tinnitus Balance- Indicator Light-

Tamper Proof mini ear hook -WindBlock- Datalogging -

Rechargeable Battery. Moderate/Severe hearing loss

Exhibit A - Sonova Phonak - Contract No. 129975 Amendment No. 4 3 of 25

Page 4: EQUIPMENT EQUIPMENT PERCENT FIXED NON - …...XXdB Max Gain/1XX dB Max Output V5261 Binaural $3,398.00 55.915% $1,498.00 $258.00 12 36 Audeo M50-13T Phonak 050-0517-H0 V5257 Monaural

Price Schedule

DESCRIPTION & FEATURES (See below) db RANGEMANUFA

CTURER

MODEL NUMBER (19

Characters or less)HCPCS CODE(S)

EQUIPMENT

PUBLISHED

LIST PRICE

EQUIPMENT PERCENT

DISCOUNT OFF LIST

PRICE

EQUIPMENT TOTAL

PRICE

FIXED NON -

WARRANTY REPAIR

PRICE

NON - WARRANTY

REPAIR PERIOD

(MONTHS)

WARRANTY REPAIR PERIOD

(MONTHS)

Sky B50-M Phonak 050-0463-01V5257 Monaural $839.00 54.112% $385.00 $129.00 12 36

68dB Max Gain/134

dB Max Output V5261 Binaural $1,678.00 54.112% $770.00 $258.00 12 36

Sky B50-P Phonak 050-0467-01 V5257 Monaural $839.00 54.112% $385.00 $129.00 12 36

71dB Max Gain/135

dB Max Output V5261 Binaural $1,678.00 54.112% $770.00 $258.00 12 36

Sky B50-SP Phonak 050-0471-01 V5257 Monaural $839.00 54.112% $385.00 $129.00 12 36

83dB Max Gain/143

dB Max Output V5261 Binaural $1,678.00 54.112% $770.00 $258.00 12 36

Sky B50-UP Phonak 050-0475-01 V5257 Monaural $839.00 54.112% $385.00 $129.00 12 36

85dB Max Gain/145

dB Max Output V5261 Binaural $1,678.00 54.112% $770.00 $258.00 12 36

Sky B50-RIC Phonak 050-0479-01 V5257 Monaural $839.00 54.112% $385.00 $129.00 12 36

72dB Max Gain/136

dB Max Output V5261 Binaural $1,678.00 54.112% $770.00 $258.00 12 36

Sky B50-PR Rechargeable (includes charger case) Phonak 050-0482-01 V5257 Monaural $1,099.00 62.693% $410.00 $129.00 12 36

71dB Max Gain/135

dB Max Output V5261 Binaural $2,198.00 62.693% $820.00 $258.00 12 36

Naida B70-UP Phonak 050-0403-01 V5257 Monaural $1,399.00 50.036% $699.00 $129.00 12 36

85dB Max Gain/145

dB Max Output V5261 Binaural $2,798.00 50.036% $1,398.00 $258.00 12 36

Naida B70-SP Phonak 050-0397-01V5257 Monaural $1,399.00 50.036% $699.00 $129.00 12 36

83dB Max Gain/143

dB Max Output V5261 Binaural $2,798.00 50.036% $1,398.00 $258.00 12 36

Naida B70-R Rechargeable (includes charger case) Phonak 050-0436-01V5257 Monaural $1,649.00 56.095% $724.00 $129.00 12 36

72dB Max Gain/136

dB Max Output V5261 Binaural $3,298.00 56.095% $1,448.00 $258.00 12 36

Digital Super Power BTE - programmable 16 channels/7 programs.

Includes APD Contrast-SoundRecover - UltraZoom Advanced-

QuickSync - WhistleBlock - NoiseBlock - Flex Volume - Zoom Control

- UserPreference - Tinnitus Balance- WindBlock WaterResistant -

Datalogging - EasyPhone - FM/DAI - Cros/BiCros compatibility - T-

Coil - Size 675 Battery. Moderate/Severe hearing loss

Digital BTE - programmable 12 channels/3 Programs. Includes

SoundRecover2-Real Ear Sound DuoPhone-QuickSync -

WhistleBlock - NoiseBlock - Flex Control- Tinnitus Balance - Indicator

Light-Tamper Proof mini ear hook -Tcoil/Roger/MyLink- Roger

(ComPilot II/Roger X) Datalogging- Rechargeable Battery.

Moderate/Severe hearing loss

Pediatric Digital BTE - programmable 12 channels/4 programs.

Includes AutoSense Sky OS- SoundRecover2 - UltraZoom -

QuickSync - WhistleBlock - NoiseBlock - Tinnitus Balance

WaterResistant - Datalogging - EasyPhone - Indicator Light-

TamperProof Battery Door-Tamper Proof mini ear hook - FM/DAI -

Cros/BiCros compatibility - Size 312 Battery. Moderate/Severe

hearing loss

Pediatric Digital BTE - programmable 12 channels/4 programs.

Includes AutoSense Sky OS- SoundRecover2 - UltraZoom -

QuickSync - WhistleBlock - NoiseBlock - Tinnitus Balance

WaterResistant - Datalogging - EasyPhone - Indicator Light-

TamperProof Battery Door-Tamper Proof mini ear hook - FM/DAI -

Cros/BiCros compatibility - Size 13 Battery. Moderate/Severe hearing

loss

Pediatric Digital Power BTE - programmable 12 channels/4

programs. Includes AutoSense Sky OS- SoundRecover2 - UltraZoom

-QuickSync - DuoPhone-Flex Control-WhistleBlock - NoiseBlock -

Tinnitus Balance WaterResistant - Datalogging - Indicator Light-

TamperProof Battery Door-Tamper Proof mini ear hook - EasyPhone

- FM/DAI - Cros/BiCros compatibility - Size 13 Battery.

Moderate/Severe hearing loss

Pediatric Digital Super Power BTE - programmable 12 channels/4

programs. Includes AutoSense Sky OS- SoundRecover2 - UltraZoom

-QuickSync - WhistleBlock - NoiseBlock - Tinnitus Balance Indicator

Light-TamperProof Battery Door-Tamper Proof mini ear hook -

WaterResistant - Datalogging - EasyPhone - FM/DAI - Cros/BiCros

compatibility - Size 675 Battery. Moderate/Severe hearing loss

Pediatric Digital RIC - programmable 12 channels/4 programs.

Includes AutoSense Sky OS- SoundRecover2 - UltraZoom

Advanced-QuickSync - WhistleBlock - NoiseBlock - Flex Volume -

Zoom Control - UserPreference - Tinnitus Balance- WindBlock

WaterResistant - Datalogging - EasyPhone - FM/DAI - Cros/BiCros

compatibility - T-Coil -Size 13 Battery. Moderate/Severe hearing loss

Digital Power BTE 16 Channels/4 programs - Includes APD

Contrast-SoundRecover2 - Sound Relax-Auto Sense OS- Music-

Wind Block- Speech in 360- Speech in Loud Noise- DuoPhone- Real

Ear Sound- Flex Control- Tinnitus Balance-Noise Block-QuickSync -

WhistleBlock - WaterResistant - Datalogging -Roger 18 Integrated

Receiver- Roger Ready- Cros B Compatibility - T-Coil/Roger MyLink-

Roger (ComPilotII/Roger X) - Size 13 Battery. Moderate/Severe

hearing loss

Digital Power RIC - programmable 16 channels/4 Programs.

Includes APD Contrast-SoundRecover2-Sound Relax-Real Ear

Sound-Flex Control-NoiseBlock-QuickSync-WhistleBlock-Roger

(ComPilotII/Roger X) - Speech in 360 - Speech in Loud Noise -

DuoPhone- Tinnitus Balance- WindBlock- Datalogging -

Rechargeable Battery. Moderate/Severe hearing loss

Exhibit A - Sonova Phonak - Contract No. 129975 Amendment No. 4 4 of 25

Page 5: EQUIPMENT EQUIPMENT PERCENT FIXED NON - …...XXdB Max Gain/1XX dB Max Output V5261 Binaural $3,398.00 55.915% $1,498.00 $258.00 12 36 Audeo M50-13T Phonak 050-0517-H0 V5257 Monaural

Price Schedule

DESCRIPTION & FEATURES (See below) db RANGEMANUFA

CTURER

MODEL NUMBER (19

Characters or less)HCPCS CODE(S)

EQUIPMENT

PUBLISHED

LIST PRICE

EQUIPMENT PERCENT

DISCOUNT OFF LIST

PRICE

EQUIPMENT TOTAL

PRICE

FIXED NON -

WARRANTY REPAIR

PRICE

NON - WARRANTY

REPAIR PERIOD

(MONTHS)

WARRANTY REPAIR PERIOD

(MONTHS)

Naida B50-UP Phonak 050-0402-01 V5257 Monaural $839.00 54.112% $385.00 $129.00 12 36

85dB Max Gain/145

dB Max Output V5261 Binaural $1,678.00 54.112% $770.00 $258.00 12 36

Naida B50-SP Phonak 050-0319-01V5257 Monaural $839.00 54.112% $385.00 $129.00 12 36

83dB Max Gain/143

dB Max Output V5261 Binaural $1,678.00 54.112% $770.00 $258.00 12 36

Naida B50-R Rechargeable (includes charger case) Phonak 050-0429-01V5257 Monaural $1,099.00 62.693% $410.00 $129.00 12 36

72dB Max Gain/136

dB Max Output V5261 Binaural $2,198.00 62.693% $820.00 $258.00 12 36

Naida B30 -UP Phonak 050-0399-01 V5257 Monaural $649.00 53.929% $299.00 $129.00 12 36

85dB Max Gain/145

dB Max Output V5261 Binaural $1,298.00 53.929% $598.00 $258.00 12 36

Naida B30 -SP Phonak 050-0318-01 V5257 Monaural $649.00 53.929% $299.00 $129.00 12 36

83dB Max Gain/143

dB Max Output V5261 Binaural $1,298.00 53.929% $598.00 $258.00 12 36

Audeo B70-R Rechargeable (includes charger case) Phonak 050-0235-01 V5257 Monaural $1,649.00 56.095% $724.00 $129.00 12 36

65dB Max Gain/133

dB Max Output V5261 Binaural $3,298.00 56.095% $1,448.00 $258.00 12 36

Audeo B50-R Rechargeable (includes charger case) Phonak 050-0234-01

V5257 Monaural $1,099.00 62.693% $410.00 $129.00 12 36

65dB Max Gain/133

dB Max Output V5261 Binaural $2,198.00 62.693% $820.00 $258.00 12 36

Bolero B70-R BTE Rechargeable (includes charger case) Phonak 050-0375-01V5257 Monaural $1,649.00 56.095% $724.00 $129.00 12 36

65dB Max Gain/133

dB Max Output V5261 Binaural $3,298.00 56.095% $1,448.00 $258.00 12 36

Bolero B50-R BTE Rechargeable (includes charger case) Phonak 050-0374-01

V5257 Monaural $1,099.00 62.693% $410.00 $258.00 12 36

65dB Max Gain/133

dB Max OutputV5261 Binaural $2,198.00 62.693% $820.00 $129.00 12 36

Digital Super Power BTE - programmable 12 channels/4 programs.

Includes APD Contrast-SoundRecover2 - UltraZoom Advanced-

QuickSync - WhistleBlock - NoiseBlock - Flex Volume - Zoom Control

- UserPreference - Tinnitus Balance- WindBlock WaterResistant -

Datalogging - DuoPhone - FM/DAI - Cros/BiCros compatibility - T-

Coil -Size 675 Battery. Moderate/Severe hearing loss

Digital Super Power BTE - programmable 8 channels/3 programs.

Includes APD Contrast- SoundRecover2 -everyday automatic -

QuickSync - WhistleBlock - Tinnitus Balance -WaterResistant -

Datalogging -Cros/BiCros compatibility - Size 675 Battery.

Moderate/Severe hearing loss

Digital Power BTE 12 Channels/3 Programs - Includes APD Contrast-

SoundRecover2-Auto Sense OS- DuoPhone-Real Ear Sound-Flex

Control- T Coil-/Roger MyLink- Roger Ready- Roger Integrated

Receiver -QuickSync - WhistleBlock - NoiseBlock - Tinnitus Balance-

WaterResistant - Datalogging - FM/DAI - CrosB compatibility - Size

13 Battery. Moderate/Severe hearing loss

Digital Power BTE 8 Channels/2 Programs- Includes APD Contrast-

AutoSense OS- Tinnitus Balance- Sound Recover2- Noise Block-

Quick Sync- Whistle Block- Cros B Compatible- T Coil/Roger MyLink-

Roger 18 Integrated Receiver-WaterResistant - Datalogging - Size

13 Battery. Moderate/Severe hearing loss

Digital Power RIC - programmable 12 channels/3 Programs.

Includes APD Contrast-SoundRecover2 -Real Ear Sound- DuoPhone-

QuickSync - WhistleBlock - NoiseBlock - Flex Control- Tinnitus

Balance - Datalogging- Rechargeable Battery. Moderate/Severe

hearing loss

Digital BTE - programmable 16 channels/4 Programs. Includes

SoundRecover2-Sound Relax-Real Ear Sound-Flex Control-

NoiseBlock-QuickSync-WhistleBlock-Roger (ComPilotII/Roger X) -

Speech in 360 - Speech in Loud Noise - DuoPhone- Tinnitus

Balance- WindBlock- Datalogging - Rechargeable Battery.

Moderate/Severe hearing loss

Digital BTE - programmable 12 channels/3 Programs. Includes

SoundRecover2 -Real Ear Sound- DuoPhone-Roger

(ComPilotII/Roger X)QuickSync - WhistleBlock - NoiseBlock - Flex

Control- Tinnitus Balance - Datalogging- Rechargeable Battery.

Moderate/Severe hearing loss

Digital BTE - programmable 16 channels/4 Programs. Includes

SoundRecover2-Sound Relax-WindBlock-NoiseBlock-WhistleBlock-

TCoil/Roger MyLink-Roger(ComPIlotII/Roger X) - Speech in 360 -

Speech in Loud Noise - DuoPhone- Tinnitus Balance- WindBlock-

Datalogging - Rechargeable Battery. Moderate/Severe hearing loss

Digital BTE - programmable 12 channels/3 Programs. Includes

SoundRecover2-Real Ear Sound DuoPhone-QuickSync -

WhistleBlock - NoiseBlock - Flex Control- Tinnitus Balance -

Tcoil/Roger/MyLink- Roger (ComPilot II/Roger X) Datalogging-

Rechargeable Battery. Moderate/Severe hearing loss

Exhibit A - Sonova Phonak - Contract No. 129975 Amendment No. 4 5 of 25

Page 6: EQUIPMENT EQUIPMENT PERCENT FIXED NON - …...XXdB Max Gain/1XX dB Max Output V5261 Binaural $3,398.00 55.915% $1,498.00 $258.00 12 36 Audeo M50-13T Phonak 050-0517-H0 V5257 Monaural

Price Schedule

DESCRIPTION & FEATURES (See below) db RANGEMANUFA

CTURER

MODEL NUMBER (19

Characters or less)HCPCS CODE(S)

EQUIPMENT

PUBLISHED

LIST PRICE

EQUIPMENT PERCENT

DISCOUNT OFF LIST

PRICE

EQUIPMENT TOTAL

PRICE

FIXED NON -

WARRANTY REPAIR

PRICE

NON - WARRANTY

REPAIR PERIOD

(MONTHS)

WARRANTY REPAIR PERIOD

(MONTHS)

Bolero B70 - P65db Max Gain - 133

Max Output Phonak 050-0368-01V5257 Monaural $1,399.00 50.036% $699.00 $129.00 12 36

V5261 Binaural $2,798.00 50.036% $1,398.00 $258.00 12 36

Bolero B70 - SP63db Max Gain - 133

Max OutputPhonak 050-0372-01

V5257 Monaural $1,399.00 50.036% $699.00 $129.00 12 36

V5261 Binaural $2,798.00 50.036% $1,398.00 $258.00 12 36

Bolero B70 - M31263db Max Gain - 133

Max OutputPhonak 050-0364-01

V5257 Monaural $1,399.00 50.036% $699.00 $129.00 12 36

V5261 Binaural $2,798.00 50.036% $1,398.00 $258.00 12 36

Bolero B50-SP70db Max Gain - 133

Max OutputPhonak

050-0371-01 V5257 Monaural $839.00 54.112% $385.00 $129.00 12 36

V5261 Binaural $1,678.00 54.112% $770.00 $258.00 12 36

Bolero B50 - P65db Max Gain - 133

Max OutputPhonak 050-0367-01

V5257 Monaural $839.00 54.112% $385.00 $129.00 12 36

V5261 Binaural $1,678.00 54.112% $770.00 $258.00 12 36

Bolero B50 - M31263db Max Gain - 133

Max OutputPhonak 050-0363-01

V5257 Monaural $839.00 54.112% $385.00 $129.00 12 36

V5261 Binaural $1,678.00 54.112% $770.00 $258.00 12 36

Bolero B30 - M31261db Max Gain - 132

Max OutputPhonak 050-0362-01

V5257 Monaural $649.00 53.929% $299.00 $129.00 12 36

V5261 Binaural $1,298.00 53.929% $598.00 $258.00 12 36

Bolero B30 -P65db Max Gain - 133

Max OutputPhonak 050-0366-01

V5257 Monaural $649.00 53.929% $299.00 $258.00 12 36

V5261 Binaural $1,298.00 53.929% $598.00 $129.00 12 36

Digital BTE 8 Channels/2 Programs- Includes AutoSense OS-

Tinnitus Balance- Sound Recover2- Noise Block- Quick Sync-

Whistle Block- Cros B Compatible- T Coil/Roger MyLink -

WaterResistant - Datalogging - Size 312 Battery. Moderate/Severe

hearing loss

Digital Power BTE 8 Channels/2 Programs- Includes AutoSense OS-

Tinnitus Balance- Sound Recover2- Noise Block- Quick Sync-

Whistle Block- Cros B Compatible- T Coil/Roger MyLink- Roger 18

Integrated Receiver- Roger Ready -WaterResistant - Datalogging -

Size 13 Battery. Moderate/Severe hearing loss

Digital Power BTE 16 Channels/4 programs - Includes

SoundRecover2 - Sound Relax-Auto Sense OS- Music- Wind Block-

Speech in 360- Speech in Loud Noise- DuoPhone- Real Ear Sound-

Flex Control- Tinnitus Balance-Noise Block-QuickSync -

WhistleBlock - WaterResistant - Datalogging -Roger 18 Integrated

Receiver- Roger Ready- Cros B Compatibility - T-Coil/Roger MyLink-

Roger (ComPilotII/Roger X) - Size13 Battery. Moderate/Severe

hearing loss

Digital Power BTE 16 Channels/4 programs - Includes

SoundRecover2 - Sound Relax-Auto Sense OS- Music- Wind Block-

Speech in 360- Speech in Loud Noise- DuoPhone- Real Ear Sound-

Flex Control- Tinnitus Balance-Noise Block-QuickSync -

WhistleBlock - WaterResistant - Datalogging -Roger 18 Integrated

Receiver- Roger Ready- Cros B Compatibility - T-Coil/Roger MyLink-

Roger (ComPilotII/Roger X) - Size 13 Battery. Moderate/Severe

hearing loss

Digital BTE 16 Channels/4 Programs - Includes SoundRecover2-

Music- QuickSync - WhistleBlock - NoiseBlock - Tinnitus Balance

Noise Generator - Flex Control- Real Ear Sound- DuoPhone- Speech

in Loud Noise -Speech in 360- Sound Relax-WindBlock-

WaterResistant - Datalogging - Cros/B Compatibility- T-

Coil/Roger/MyLink-Roger 18 Integrated Receiver-

Roger(ComPilotii/Roger X) - Size 312 Battery. Moderate/Severe

hearing loss

Digital Super Power BTE 12 Channels/3 Programs - Includes

SoundRecover2-Auto Sense OS- DuoPhone-Real Ear Sound-Flex

Control- T Coil-/Roger MyLink- Roger Ready- Roger Integrated

Receiver -QuickSync - WhistleBlock - NoiseBlock - Tinnitus Balance-

WaterResistant - Datalogging - FM/DAI - CrosB compatibility - Size

13 Battery. Moderate/Severe hearing loss

Digital Power BTE 12 Channels/3 Programs- Includes

SoundRecover2-Auto Sense OS- DuoPhone-Real Ear Sound-Flex

Control- T Coil-/Roger MyLink- Roger Ready- Roger 18 Integrated

Receiver -QuickSync - WhistleBlock - NoiseBlock - Tinnitus Balance-

WaterResistant - Datalogging- CrosB compatibility - Size 13 Battery.

Moderate/Severe hearing loss

Digital BTE 12 Channels/3 Programs - Includes SoundRecover2-

Auto Sense OS- DuoPhone-Real Ear Sound-Flex Control- T Coil-

/Roger MyLink-QuickSync - WhistleBlock - NoiseBlock - Tinnitus

Balance- WaterResistant - Datalogging - CrosB compatibility - Size

312 Battery. Moderate/Severe hearing loss

Exhibit A - Sonova Phonak - Contract No. 129975 Amendment No. 4 6 of 25

Page 7: EQUIPMENT EQUIPMENT PERCENT FIXED NON - …...XXdB Max Gain/1XX dB Max Output V5261 Binaural $3,398.00 55.915% $1,498.00 $258.00 12 36 Audeo M50-13T Phonak 050-0517-H0 V5257 Monaural

Price Schedule

DESCRIPTION & FEATURES (See below) db RANGEMANUFA

CTURER

MODEL NUMBER (19

Characters or less)HCPCS CODE(S)

EQUIPMENT

PUBLISHED

LIST PRICE

EQUIPMENT PERCENT

DISCOUNT OFF LIST

PRICE

EQUIPMENT TOTAL

PRICE

FIXED NON -

WARRANTY REPAIR

PRICE

NON - WARRANTY

REPAIR PERIOD

(MONTHS)

WARRANTY REPAIR PERIOD

(MONTHS)

Bolero B30 -SP70db Max Gain - 133

Max Output Phonak 050-0370-01V5257 Monaural $649.00 53.929% $299.00 $129.00 12 36

V5261 Binaural $1,298.00 53.929% $598.00 $258.00 12 36

Audeo B70 RIC -1046db Max Gain - 124

Max OutputPhonak 050-0348-01

V5257 Monaural $1,399.00 50.036% $699.00 $129.00 12 36

V5261 Binaural $2,798.00 50.036% $1,398.00 $258.00 12 36

Audeo B70 RIC-31246 dB Max gain /130

dB Max output Phonak 050-00352-01V5257 Monaural $1,399.00 50.036% $699.00 $129.00 12 36

V5261 Binaural $2,798.00 50.036% $1,398.00 $258.00 12 36

Audeo B70 RIC-312T 46 dB Max Gain/130

dB Max Output Phonak 050-0356-01V5257 Monaural $1,399.00 50.036% $699.00 $129.00 12 36

V5261 Binaural $2,798.00 50.036% $1,398.00 $258.00 12 36

Audeo B70 RIC-1346 dB Max Gain/130

dB Max OutputPhonak 050-03560-01

V5257 Monaural $1,399.00 50.036% $699.00 $129.00 12 36

V5261 Binaural $2,798.00 50.036% $1,398.00 $258.00 12 36

Audeo B50 RIC-1046 dB Max Gain/124

dB Max OutputPhonak 050-0347-01

V5257 Monaural $839.00 54.112% $385.00 $129.00 12 36

V5261 Binaural $1,678.00 54.112% $770.00 $258.00 12 36

Audeo B50 RIC-31246 dB Max Gain/130

Max OutputPhonak 050-0351-01

V5257 Monaural $839.00 54.112% $385.00 $129.00 12 36

V5261 Binaural $1,678.00 54.112% $770.00 $258.00 12 36

Audeo B50-312 T46 dB Max Gain/130

dB Max OutputPhonak 050-0355-01

V5257 Monaural $839.00 54.112% $385.00 $129.00 12 36

V5261 Binaural $1,678.00 54.112% $770.00 $258.00 12 36

Audeo B50-1346 dB Max Gain/130

dB Max OutputPhonak 050-0359-01

V5257 Monaural $839.00 54.112% $385.00 $129.00 12 36

V5261 Binaural $1,678.00 54.112% $770.00 $258.00 12 36

Digital Super Power BTE 8 Channels/2 Programs- Includes

AutoSense OS- Tinnitus Balance- Sound Recover2- Noise Block-

Quick Sync- Whistle Block- Cros B Compatible- T Coil/Roger MyLink-

Roger 18 Integrated Receiver-WaterResistant - Datalogging - Size

13 Battery. Moderate/Severe hearing loss

Digital RIC - programmable 16 channels/4 Programs. Includes

SoundRecover2 - Sound Relax- Wind Block- Speech in Loud Noise-

Real Ear Sound-Speech in 360 - Speech in Loud Noise - DuoPhone -

QuickSync - WhistleBlock - NoiseBlock - Flex Control - Tinnitus

Balance- WindBlock- Datalogging - Cros B/BiCros compatibility -

Roger 18 Integrated Receiver-Roger Ready-T Coil - Size 13 Battery.

Moderate/Severe hearing loss

Digital RIC - programmable 12 channels/3 Programs. Includes

SoundRecover2 - DuoPhone - Tinnitus Balance-QuickSync -

WhistleBlock - NoiseBlock - Flex Control-Tinnitus Balance-Real Ear

Sound- Datalogging - CrosB /BiCros compatibility-T Coil-Roger

(ComPilot II/Roger X) Size 10a Battery. Mild-Moderate/Severe

hearing loss

Digital RIC - programmable 12 channels/4 Programs. Includes

SoundRecover2 - DuoPhone-QuickSync - WhistleBlock - NoiseBlock -

Flex Control- Tinnitus Balance- Real Ear Sound-Datalogging- Cros

B/BiCros compatibility-Roger(Com Pilot II/Roger X) - Size 312

Battery. Moderate/Severe hearing loss

Digital RIC - programmable 12 channels/ 4 Programs. Includes

SoundRecover2 - DuoPhone-QuickSync - WhistleBlock - NoiseBlock -

Flex Control - Tinnitus Balance - Datalogging -Tcoil Roger MyLink-

Cros B/BiCros compatibility - Size 312 Battery. Moderate/Severe

hearing loss

Digital RIC - programmable 12 channels/4 Programs. Includes

SoundRecover2 -Real Ear Sound- DuoPhone - UltraZoom Advanced-

QuickSync - WhistleBlock - NoiseBlock - Flex Control - Tinnitus

Balance - Datalogging- Cros B/BiCros compatibility-Roger/MyLink-

Roger Integrated Receiver 18-Roger Ready - Size 13 Battery.

Moderate/Severe hearing loss

Digital RIC - programmable 16 channels/4 Programs. Includes

SoundRecover2 - Speech in 360 - Speech in Loud Noise -

DuoPhone-QuickSync - WhistleBlock - NoiseBlock - Flex Control -

Tinnitus Balance- WindBlock-Sound Relax-Real Ear Sound

Datalogging - Cros B/BiCros compatibility - Size 312 Battery.

Moderate/Severe hearing loss

Digital RIC - programmable 16 channels/4 Programs. Includes

SoundRecover2 - Speech in 360 - Speech in Loud Noise -Real Ear

Sound- DuoPhone -QuickSync - WhistleBlock - NoiseBlock - Flex

Control - Tinnitus Balance- WindBlock- Sound Relax-Datalogging -

Telecoil- CrosB/BiCros compatibility - Size 312 Battery.

Moderate/Severe hearing loss

Digital RIC - programmable 16 channels/4 programs. Includes

SoundRecover2 - Wind Block- Sound Relax-Speech in 360 - Speech

in Loud Noise - DuoPhone -QuickSync - WhistleBlock - NoiseBlock -

Flex Control - Tinnitus Balance-Sound Relax-Real Ear Sound -

Datalogging- Cros B/BiCros compatibility - Size 10a Battery. Mild-

Moderate/Severe hearing loss

Exhibit A - Sonova Phonak - Contract No. 129975 Amendment No. 4 7 of 25

Page 8: EQUIPMENT EQUIPMENT PERCENT FIXED NON - …...XXdB Max Gain/1XX dB Max Output V5261 Binaural $3,398.00 55.915% $1,498.00 $258.00 12 36 Audeo M50-13T Phonak 050-0517-H0 V5257 Monaural

Price Schedule

DESCRIPTION & FEATURES (See below) db RANGEMANUFA

CTURER

MODEL NUMBER (19

Characters or less)HCPCS CODE(S)

EQUIPMENT

PUBLISHED

LIST PRICE

EQUIPMENT PERCENT

DISCOUNT OFF LIST

PRICE

EQUIPMENT TOTAL

PRICE

FIXED NON -

WARRANTY REPAIR

PRICE

NON - WARRANTY

REPAIR PERIOD

(MONTHS)

WARRANTY REPAIR PERIOD

(MONTHS)

Audeo B30-10

46 Max Gain/ 130 dB

Max Output Phonak 050-0346-01

V5257 Monaural $649.00 53.929% $299.00 $129.00 12 36

V5261 Binaural $1,298.00 53.929% $598.00 $258.00 12 36

Audeo B30 31246 dB Max Gain/130

dB Max OutputPhonak 050-0350-01

V5257 Monaural $649.00 53.929% $299.00 $129.00 12 36

V5261 Binaural $1,298.00 53.929% $598.00 $258.00 12 36

Audeo B30-312 T46 dB Max Gain/130

dB Max OutputPhonak 050-0354-01

V5257 Monaural $649.00 53.929% $299.00 $129.00 12 36

V5261 Binaural $1,298.00 53.929% $598.00 $258.00 12 36

Audeo B30-1346 dB/130 dB

Phonak 050-0358-01V5257 Monaural $649.00 53.929% $299.00 $129.00 12 36

V5261 Binaural $1,298.00 53.929% $598.00 $258.00 12 36

CROS B R- Rechargeable 70 level60 dB Max Gain -122

Output Phonak 050-0601-01.70V5181 $2,478.00 53.855% $1,143.47 $110.00 12 24

Designed for those with Unilateral hearing loss. Transfers the

microphone input signal to a rechargeable Audeo B Rechargeable

battery

CROS B R- Rechargeable 70 level (BiCROS)60 dB Max Gain -122

Output Phonak 050-0601-01.70V5221 $2,478.00 53.855% $1,143.47 $110.00 12 24

Designed for those with Bilateral hearing loss. Transfers the

microphone input signal to a rechargeable Audeo B Rechargeable

battery

CROS B R- Rechargeable 50 level60 dB Max Gain -122

Output Phonak 050-0601-01.50V5181 $1,928.00 56.977% $829.48 $110.00 12 24

Designed for those with Unilateral hearing loss. Transfers the

microphone input signal to a rechargeable Audeo B Rechargeable

battery

CROS B R- Rechargeable 50 level (BiCROS)60 dB Max Gain -122

Output Phonak 050-0601-01.50V5221 $1,928.00 56.977% $829.48 $110.00 12 24

Designed for those with Bilateral hearing loss. Transfers the

microphone input signal to a rechargeable Audeo B Rechargeable

battery

CROS B 312- 30 level (excludes all rechargeable BTE/RIC)60 dB Max Gain -122

Output Phonak 050-0274-01.30V5181 $1,398.00 51.502% $678.00 $110.00 12 24

Designed for those with Unilateral hearing loss. Transfers the

microphone input signal to any model of Phonak Belong Audeo &

Bolero

CROS B 312- 30 level (excludes all rechargeable BTE/RIC) (BiCROS)60 dB Max Gain -122

Output Phonak 050-0274-01.30V5221 $1,398.00 51.502% $678.00 $110.00 12 24

Designed for those with Bilateral hearing loss. Transfers the

microphone input signal to any model of Phonak Belong Audeo &

Bolero

CROS B 13- 30 level (excludes all rechargeable BTE/RIC)63 dB Max Gain -122

OutputPhonak 050-0275-01.30

V5181 $1,398.00 51.502% $678.00 $110.00 12 24

Designed for those with Unilateral hearing loss. Transfers the

microphone input signal to any model of Phonak Belong Audeo &

Bolero

CROS B 13- 30 level (excludes all rechargeable BTE/RIC) (BiCROS)63 dB Max Gain -122

OutputPhonak 050-0275-01.30

V5221 $1,398.00 51.502% $678.00 $110.00 12 24

Designed for those with Bilateral hearing loss. Transfers the

microphone input signal to any model of Phonak Belong Audeo &

Bolero

Digital RIC - programmable 8 channels/2 Programs. Includes

SoundRecover2 -QuickSync - WhistleBlock - NoiseBlock- Tinnitus

Balance - Datalogging -Cros B/BiCros compatibility-Roger (ComPilot

II/Roger X) - Size 10 Battery. Mild-Moderate/Severe hearing loss

Digital RIC - programmable 8 channels/2 Programs. Includes Sound

Recover2-QuickSync - WhistleBlock - NoiseBlock - Tinnitus Balance -

Datalogging - Cros B/BiCros compatibility -Roger (ComPilot II/Roger

X) - Size 312 Battery. Moderate/Severe hearing loss

Digital RIC - programmable 8 channels/2 Programs. Includes

SoundRecover2 -QuickSync - WhistleBlock - NoiseBlock - Tinnitus

Balance- T-Coil/ Roger MyLink- Roger (ComPilot II/Roger X-

Datalogging- Cros B/BiCros compatibility- Size 312 Battery.

Moderate/Severe hearing loss

Digital RIC - programmable 8 channels/2 Programs. Includes

SoundRecover2-QuickSync - WhistleBlock - NoiseBlock - Tinnitus

Balance - Datalogging- CrosB/BiCros compatibility -T Coil/Roger

MyLink-Roger (ComPilotII/RogerX) - Size 13 Battery.

Moderate/Severe hearing loss

Exhibit A - Sonova Phonak - Contract No. 129975 Amendment No. 4 8 of 25

Page 9: EQUIPMENT EQUIPMENT PERCENT FIXED NON - …...XXdB Max Gain/1XX dB Max Output V5261 Binaural $3,398.00 55.915% $1,498.00 $258.00 12 36 Audeo M50-13T Phonak 050-0517-H0 V5257 Monaural

Price Schedule

DESCRIPTION & FEATURES (See below) db RANGEMANUFA

CTURER

MODEL NUMBER (19

Characters or less)HCPCS CODE(S)

EQUIPMENT

PUBLISHED

LIST PRICE

EQUIPMENT PERCENT

DISCOUNT OFF LIST

PRICE

EQUIPMENT TOTAL

PRICE

FIXED NON -

WARRANTY REPAIR

PRICE

NON - WARRANTY

REPAIR PERIOD

(MONTHS)

WARRANTY REPAIR PERIOD

(MONTHS)

CROS B 312 - 50 level (excludes all rechargeable BTE/RIC) Phonak 050-0274-01.50V5181 $1,588.00 51.889% $764.00 $110.00 12 24

60db Max Gain - 122

CROS B 312 - 50 level (excludes all rechargeable BTE/RIC) (BiCROS) Phonak 050-0274-01.50V5221 $1,588.00 51.889% $764.00 $110.00 12 24

60db Max Gain - 122

CROS B 13 - 50 level (excludes all rechargeable BTE/RIC) Phonak 050-0275-01.50V5181 $1,588.00 51.889% $764.00 $110.00 12 24

63db Max Gain - 133

Max Output

CROS B 13 - 50 level (excludes all rechargeable BTE/RIC) (BiCROS) Phonak 050-0275-01.50V5221 $1,588.00 51.889% $764.00 $110.00 12 24

63db Max Gain - 133

Max Output

CROS B 312 - 70 level (excludes all rechargeable BTE/RIC) Phonak 050-0274-01.70V5181 $2,148.00 49.814% $1,078.00 $110.00 12 24

60db Max Gain - 122

Max Output

CROS B 312 - 70 level (excludes all rechargeable BTE/RIC) (BiCROS) Phonak 050-0274-01.70V5221 $2,148.00 49.814% $1,078.00 $110.00 12 24

60db Max Gain - 122

Max Output

CROS B 13 - 70 level (excludes all rechargeable BTE/RIC) Phonak 050-0275.01.70

V5181 $2,148.00 49.814% $1,078.00 $110.00 12 24

63db Max Gain - 133

Max Output

CROS B 13 - 70 level (excludes all rechargeable BTE/RIC) (BiCROS) Phonak 050-0275.01.70

V5221 $2,148.00 49.814% $1,078.00 $110.00 12 24

63db Max Gain - 133

Max Output

Bolero V70- M 31261db Max Gain - 133

Max OutputPhonak 050-0283-01

V5257 Monaural $1,349.00 48.184% $699.00 $129.00 12 36

V5261 Binaural $2,698.00 48.184% $1,398.00 $258.00 12 36

Bolero V70 - P65db Max Gain - 133

Max OutputPhonak 050-0291-01

V5257 Monaural $1,349.00 48.184% $699.00 $129.00 12 36

V5261 Binaural $2,698.00 48.184% $1,398.00 $258.00 12 36

Bolero V70-SP70db Max Gain - 133

Max OutputPhonak 050-0295-01

V5257 Monaural $1,349.00 48.184% $699.00 $129.00 12 36

V5261 Binaural $2,698.00 48.184% $1,398.00 $258.00 12 36

Digital BTE, AutoSense OS, Speech in 360, Speech in Loud Noise,

Wind Block, SoundRelax, SNR-Boost, FlexControl, Flex Volume,

DuoPhone, Real Ear Sound, WhistleBlock, NoiseBlock, Quick Sync,

SoundRecover, Tinnitus Balance, auto Acclimatization, UltraZoom

Advanced, 16 channels, WCP compatible, size 312 battery, Roger

compatible, telecoil

Digital BTE, Power, AutoSense OS, Speech in 360, Speech in Loud

Noise, Wind Block, SoundRelax, SNR-Boost, FlexControl, Flex

Volume, DuoPhone, Real Ear Sound, WhistleBlock, NoiseBlock,

Quick Sync, SoundRecover, Tinnitus Balance, auto Acclimatization,

UltraZoom Advanced, 16 channels, WCP compatible, size 13

battery, Roger compatible, telecoil

Digital BTE, Super Power,AutoSense OS, Speech in 360, Speech in

Loud Noise, Wind Block, SoundRelax, SNR-Boost, FlexControl, Flex

Volume, DuoPhone, Real Ear Sound, WhistleBlock, NoiseBlock,

Quick Sync, SoundRecover, Tinnitus Balance, auto Acclimatization,

UltraZoom Advanced, 16 channels, WCP compatible, size 13

battery, Roger compatible, telecoil

Designed for those with Unilateral hearing loss. Transfers the

microphone input signal to any model of Phonak Belong Audeo &

Bolero

Designed for those with Unilateral hearing loss. Transfers the

microphone input signal to any model of Phonak Belong Audeo &

Bolero

Designed for those with Unilateral hearing loss. Transfers the

microphone input signal to any model of Phonak Belong Audeo &

Bolero

Designed for those with Bilateral hearing loss. Transfers the

microphone input signal to any model of Phonak Belong Audeo &

Bolero

Designed for those with Unilateral hearing loss. Transfers the

microphone input signal to any model of Phonak Belong Audeo &

Bolero

Designed for those with Bilateral hearing loss. Transfers the

microphone input signal to any model of Phonak Belong Audeo &

Bolero

Designed for those with Bilateral hearing loss. Transfers the

microphone input signal to any model of Phonak Belong Audeo &

Bolero

Designed for those with Unilateral hearing loss. Transfers the

microphone input signal to any model of Phonak Belong Audeo &

Bolero

Exhibit A - Sonova Phonak - Contract No. 129975 Amendment No. 4 9 of 25

Page 10: EQUIPMENT EQUIPMENT PERCENT FIXED NON - …...XXdB Max Gain/1XX dB Max Output V5261 Binaural $3,398.00 55.915% $1,498.00 $258.00 12 36 Audeo M50-13T Phonak 050-0517-H0 V5257 Monaural

Price Schedule

DESCRIPTION & FEATURES (See below) db RANGEMANUFA

CTURER

MODEL NUMBER (19

Characters or less)HCPCS CODE(S)

EQUIPMENT

PUBLISHED

LIST PRICE

EQUIPMENT PERCENT

DISCOUNT OFF LIST

PRICE

EQUIPMENT TOTAL

PRICE

FIXED NON -

WARRANTY REPAIR

PRICE

NON - WARRANTY

REPAIR PERIOD

(MONTHS)

WARRANTY REPAIR PERIOD

(MONTHS)

Bolero V50 - M63db Max Gain - 133

Max OutputPhonak 050-0282-01

V5257 Monaural $799.00 51.815% $385.00 $129.00 12 36

V5261 Binaural $1,598.00 51.815% $770.00 $258.00 12 36

Bolero V50 - P65db Max Gain - 133

Max Output Phonak 050-0290-01V5257 Monaural $799.00 51.815% $385.00 $129.00 12 36

V5261 Binaural $1,598.00 51.815% $770.00 $258.00 12 36

Bolero V50 - SP70db Max Gain - 133

Max OutputPhonak 050-0294-01

V5257 Monaural $799.00 51.815% $385.00 $129.00 12 36

V5261 Binaural $1,598.00 51.815% $770.00 $258.00 12 36

Bolero V30 - M63db Max Gain - 133

Max Output Phonak 050-0281-01V5257 Monaural $629.00 52.464% $299.00 $129.00 12 36

V5261 Binaural $1,258.00 52.464% $598.00 $258.00 12 36

Bolero V30 - P65db Max Gain - 133

Max Output Phonak 050-0289-01V5257 Monaural $629.00 52.464% $299.00 $129.00 12 36

V5261 Binaural $1,258.00 52.464% $598.00 $258.00 12 36

Bolero V30 - SP70db Max Gain - 133

Max Output Phonak 050-0293-01V5257 Monaural $629.00 52.464% $299.00 $129.00 12 36

V5261 Binaural $1,258.00 52.464% $598.00 $258.00 12 36

Sky V70 - M63db Max Gain - 133

Max OutputPhonak 050-0328-01

V5257 Monaural $1,349.00 48.184% $699.00 $129.00 12 36

V5261 Binaural $2,698.00 48.184% $1,398.00 $258.00 12 36

Sky V-70 P82db Max Gain - 142

Max Output Phonak 050-0332-01V5257 Monaural $1,349.00 48.184% $699.00 $129.00 12 36

V5261 Binaural $2,698.00 48.184% $1,398.00 $258.00 12 36

Sky V-70 RIC65db Max Gain - 133

Max Output Phonak 050-0344-01V5257 Monaural $1,349.00 48.184% $699.00 $129.00 12 36

V5261 Binaural $2,698.00 48.184% $1,398.00 $258.00 12 36

Pediatric Digital BTE - programmable 16 channels/7 programs.

Includes SoundRecover2 -DuoPhone- UltraZoom Advanced-

QuickSync Indicator Light-TamperProof Battery Door-Tamper Proof

mini ear hook - WhistleBlock - NoiseBlock - Flex Control - Zoom

Control - UserPreference -Duo Phone- WindBlock-Sound Relax-

Roger Ready-WaterResistant - Datalogging - FM/DAI - Cros/BiCros

compatibility - T-Coil -RogerMy Link- Size 312 Battery.

Moderate/Severe hearing loss

Pediatric Digital Super Power BTE - programmable 16 channels/7

programs. Includes SoundRecover2 - DuoPhone-Roger Ready-

Indicator Light-Tamper Proof Battery Door-Tamper Proof Ear Hook-

UltraZoom Advanced-QuickSync - WhistleBlock - NoiseBlock - Flex

Control - UserPreference - Tinnitus Balance- WindBlock-Sound

Relax- WaterResistant - Datalogging - DuoPhone - FM/DAI -

Cros/BiCros compatibility - T-Coil -Roger My Link - Size 13 Battery.

Moderate/Severe hearing loss

Pediatric Digital RIC - programmable 16 channels/7 programs.

Includes SoundRecover2 - UltraZoom Advanced-QuickSync -

WhistleBlock - NoiseBlock - Flex Volume - Zoom Control -

UserPreference - Tinnitus Balance- WindBlock WaterResistant -

Datalogging - DuoPhone - FM/DAI - Cros/BiCros compatibility - T-

Coil - Size 13 Battery. Moderate/Severe hearing loss

Digital BTE, Super Power, AutoSense OS, SNR-Boost, FlexControl,

Flex Volume, DuoPhone, Real Ear Sound, WhistleBlock, NoiseBlock,

Quick Sync, SoundRecover, Tinnitus Balance, auto Acclimatization,

UltraZoom Standard, 12 channels, WCP compatible, size 13 battery,

telecoil, Roger compatible

Digital BTE,AutoSense OS, SNR-Boost, FlexControl, Flex Volume,

DuoPhone, Real Ear Sound, WhistleBlock, NoiseBlock, Quick Sync,

SoundRecover, Tinnitus Balance, auto Acclimatization, UltraZoom

Standard, 12 channels, WCP compatible, size 312 battery, telecoil,

Roger compatible

Digital BTE, Power, AutoSense OS, SNR-Boost, FlexControl, Flex

Volume, DuoPhone, Real Ear Sound, WhistleBlock, NoiseBlock,

Quick Sync, SoundRecover, Tinnitus Balance, auto Acclimatization,

UltraZoom Standard, 12 channels, WCP compatible, size 13 battery,

telecoil, Roger compatible

Digital BTE, AutoSense OS, WhistleBlock, NoiseBlock, Quick Sync,

SoundRecover, Tinnitus Balance, auto Acclimatization, UltraZoom

Essential, 8 channels, WCP compatible, size 312 battery, Roger

compatible, telecoil

Digital BTE, AutoSense OS, WhistleBlock, NoiseBlock, Quick Sync,

SoundRecover, Tinnitus Balance, auto Acclimatization, UltraZoom

Essential, 8 channels, WCP compatible, size 13 battery, Roger

compatible, telecoil

Digital BTE, AutoSense OS, WhistleBlock, NoiseBlock, Quick Sync,

SoundRecover, Tinnitus Balance, auto Acclimatization, UltraZoom

Essential, 8 channels, WCP compatible, size 13 battery, Roger

compatible, telecoil

Exhibit A - Sonova Phonak - Contract No. 129975 Amendment No. 4 10 of 25

Page 11: EQUIPMENT EQUIPMENT PERCENT FIXED NON - …...XXdB Max Gain/1XX dB Max Output V5261 Binaural $3,398.00 55.915% $1,498.00 $258.00 12 36 Audeo M50-13T Phonak 050-0517-H0 V5257 Monaural

Price Schedule

DESCRIPTION & FEATURES (See below) db RANGEMANUFA

CTURER

MODEL NUMBER (19

Characters or less)HCPCS CODE(S)

EQUIPMENT

PUBLISHED

LIST PRICE

EQUIPMENT PERCENT

DISCOUNT OFF LIST

PRICE

EQUIPMENT TOTAL

PRICE

FIXED NON -

WARRANTY REPAIR

PRICE

NON - WARRANTY

REPAIR PERIOD

(MONTHS)

WARRANTY REPAIR PERIOD

(MONTHS)

Sky V70 - SP 63db Max Gain - 133

Max OutputPhonak 050-0336-01

V5257 Monaural $1,349.00 48.184% $699.00 $129.00 12 36

V5261 Binaural $2,698.00 48.184% $1,398.00 $258.00 12 36

Sky V-70 UP82db Max Gain - 142

Max Output Phonak 050-0340-01V5257 Monaural $1,349.00 48.184% $699.00 $129.00 12 36

V5261 Binaural $2,698.00 48.184% $1,398.00 $258.00 12 36

Sky V-50 SP75db Max Gain - 140

Max OutputPhonak 050-0335-01

V5257 Monaural $799.00 51.815% $385.00 $129.00 12 36

V5261 Binaural $1,598.00 51.815% $770.00 $258.00 12 36

Sky V-50 RIC65db Max Gain - 133

Max OutputPhonak 050-0343-01

V5257 Monaural $799.00 51.815% $385.00 $129.00 12 36

V5261 Binaural $1,598.00 51.815% $770.00 $258.00 12 36

Sky V50 - M63db Max Gain - 133

Max Output Phonak 050-0327-01V5257 Monaural $799.00 51.815% $385.00 $129.00 12 36

V5261 Binaural $1,598.00 51.815% $770.00 $258.00 12 36

Sky V50 - P

63db Max Gain - 133

Max Output Phonak 050-0331-01

V5257 Monaural $799.00 51.815% $385.00 $129.00 12 36

V5261 Binaural $1,598.00 51.815% $770.00 $258.00 12 36

Sky V50-UP82db Max Gain - 133

Max Output050-0339-01

V5257 Monaural $799.00 51.815% $385.00 $129.00 12 36

V5261 Binaural $1,598.00 51.815% $770.00 $258.00 12 36

Naida V-70 SP75db Max Gain - 140

Max Output Phonak 050-0244-01V5257 Monaural $1,349.00 48.184% $699.00 $129.00 12 36

V5261 Binaural $2,698.00 48.184% $1,398.00 $258.00 12

Pediatric Digital BTE - programmable 16 channels/7 programs.

Includes SoundRecover2 - UltraZoom Advanced-QuickSync -

WhistleBlock - NoiseBlock - Flex Control - Zoom Control -

UserPreference - Tinnitus Balance-Duo Phone- WindBlock-Sound

Relax- WaterResistant - Datalogging - FM/DAI - Cros/BiCros

compatibility - T-Coil -RogerMy Link-Indicator Light-Tamperproof

Battery Door-Tamperproof Mini ear hook-Size 13 Battery.

Moderate/Severe hearing loss

Pediatric Digital Super Power BTE - programmable 16 channels/7

programs. Includes SoundRecover2 - UltraZoom Advanced-

QuickSync - WhistleBlock - NoiseBlock - Flex Control -

UserPreference - Tinnitus Balance- WindBlock-Sound Relax-

WaterResistant - Datalogging - DuoPhone - FM/DAI - Cros/BiCros

compatibility - T-Coil -Roger My Link-Size 675 Battery.

Moderate/Severe hearing loss

Pediatric Digital Super Power BTE - programmable 12 channels/4

programs. Includes SoundRecover2 - UltraZoom -QuickSync -

DuoPhone-Flex Control-WhistleBlock - NoiseBlock - Tinnitus Balance

WaterResistant - Datalogging - EasyPhone - FM/DAI - Cros/BiCros

compatibility - Size 13 Battery. Moderate/Severe hearing loss

Pediatric Digital RIC - programmable 12 channels/4 programs.

Includes SoundRecover2 - UltraZoom Advanced-QuickSync -

WhistleBlock - NoiseBlock - Flex Volume - Zoom Control -

UserPreference - Tinnitus Balance- WindBlock WaterResistant -

Datalogging - EasyPhone - FM/DAI - Cros/BiCros compatibility - T-

Coil - Size 13 Battery. Moderate/Severe hearing loss

Pediatric Digital BTE - programmable 12 channels/4 programs.

Includes SoundRecover2 - UltraZoom -QuickSync - WhistleBlock -

NoiseBlock - Tinnitus Balance WaterResistant - Datalogging -

EasyPhone - FM/DAI - Cros/BiCros compatibility - Size 312 Battery.

Moderate/Severe hearing loss

Pediatric Digital BTE - programmable 12 channels/4 programs.

Includes SoundRecover2 - UltraZoom -QuickSync - WhistleBlock -

NoiseBlock - Tinnitus Balance WaterResistant - Datalogging -

EasyPhone - FM/DAI - Cros/BiCros compatibility - Size 13 Battery.

Moderate/Severe hearing loss

Pediatric Digital BTE - programmable 12 channels/4 programs.

Includes SoundRecover2 - UltraZoom -QuickSync - WhistleBlock -

NoiseBlock - Tinnitus Balance WaterResistant - Datalogging -

EasyPhone - FM/DAI - Cros/BiCros compatibility - Size 675 Battery.

Moderate/Severe hearing loss

Digital Super Power BTE - programmable 16 channels/7 programs.

Includes SoundRecover2 - UltraZoom Advanced-QuickSync -

WhistleBlock - NoiseBlock - Flex Volume - Zoom Control -

UserPreference - Tinnitus Balance- WindBlock WaterResistant -

Datalogging - EasyPhone - FM/DAI - Cros/BiCros compatibility -

Size 13 Battery. Moderate/Severe hearing loss

Exhibit A - Sonova Phonak - Contract No. 129975 Amendment No. 4 11 of 25

Page 12: EQUIPMENT EQUIPMENT PERCENT FIXED NON - …...XXdB Max Gain/1XX dB Max Output V5261 Binaural $3,398.00 55.915% $1,498.00 $258.00 12 36 Audeo M50-13T Phonak 050-0517-H0 V5257 Monaural

Price Schedule

DESCRIPTION & FEATURES (See below) db RANGEMANUFA

CTURER

MODEL NUMBER (19

Characters or less)HCPCS CODE(S)

EQUIPMENT

PUBLISHED

LIST PRICE

EQUIPMENT PERCENT

DISCOUNT OFF LIST

PRICE

EQUIPMENT TOTAL

PRICE

FIXED NON -

WARRANTY REPAIR

PRICE

NON - WARRANTY

REPAIR PERIOD

(MONTHS)

WARRANTY REPAIR PERIOD

(MONTHS)

Naida V-70 UP82db Max Gain - 142

Max OutputPhonak 050-0248-01

V5257 Monaural $1,349.00 48.184% $699.00 $129.00 12 36

V5261 Binaural $2,698.00 48.184% $1,398.00 $258.00 12 36

Naida V-70 RIC65db Max Gain - 133

Max Output Phonak 050-0267-01

V5257 Monaural $1,349.00 48.184% $699.00 $129.00 12 36

V5261 Binaural $2,698.00 48.184% $1,398.00 $258.00 12 36

Naida V-50 UP82db Max Gain - 142

Max OutputPhonak 050-0247-01

V5257 Monaural $799.00 51.815% $385.00 $129.00 12 36

V5261 Binaural $1,598.00 51.815% $770.00 $258.00 12 36

Naida V-50 SP75db Max Gain - 140

Max OutputPhonak 050-0243-01

V5257 Monaural $799.00 51.815% $385.00 $129.00 12 36

V5261 Binaural $1,598.00 51.815% $770.00 $258.00 12 36

Naida V-50 RIC

65db Max Gain - 133

Max Output Phonak 050-0266-01

V5257 Monaural $799.00 51.815% $385.00 $129.00 12 36

V5261 Binaural $1,598.00 51.815% $770.00 $258.00 12 36

Naida V-30 UP82db Max Gain - 142

Max OutputPhonak 050-0246-01

V5257 Monaural $629.00 52.464% $299.00 $129.00 12 36

V5261 Binaural $1,258.00 52.464% $598.00 $258.00 12 36

Naida V-30 SP75db Max Gain - 140

Max Output Phonak 050-0242-01V5257 Monaural $629.00 52.464% $299.00 $129.00 12 36

V5261 Binaural $1,258.00 52.464% $598.00 $258.00 12 36

Naida V-30 RIC Phonak 050-0265-01V5257 Monaural $629.00 52.464% $299.00 $129.00 12 36

65db Max Gain - 133

Max Output

V5261 Binaural $1,258.00 52.464% $598.00 $258.00 12 36

CROS II 312 - BTE Venture Package 30 level Phonak 050-0228-01.30V5181 $1,378.00 50.798% $678.00 $110.00 12 24

60db Max Gain - 122 Designed for those with Unilateral hearing loss. Transfers the

microphone input signal to any model of Phonak Audéo V and Bolero

V

Digital BTE - programmable 12 channels/4 programs. Includes

SoundRecover - UltraZoom Advanced-QuickSync - WhistleBlock -

NoiseBlock - Flex Volume - Zoom Control - UserPreference - Tinnitus

Balance- WindBlock WaterResistant - Datalogging - EasyPhone -

FM/DAI - Cros/BiCros compatibility - T-Coil - Size 13 Battery.

Moderate/Severe hearing loss

Digital Super Power BTE - programmable 8 channels/3 programs.

Includes SoundRecover2 -everyday automatic -QuickSync -

WhistleBlock - Tinnitus Balance -WaterResistant - Datalogging -

Cros/BiCros compatibility - Size 675 Battery. Moderate/Severe

hearing loss

Digital Super Power BTE - programmable 8 channels/3 programs.

Includes SoundRecover2 -everyday automatic -QuickSync -

WhistleBlock - Tinnitus Balance -WaterResistant - Datalogging -

Cros/BiCros compatibility - Size 13 Battery. Moderate/Severe

hearing loss

Digital BTE - programmable 8 channels/3 programs. Includes

SoundRecover - UltraZoom Advanced-QuickSync - WhistleBlock -

NoiseBlock - Flex Volume - Zoom Control - UserPreference - Tinnitus

Balance- WindBlock WaterResistant - Datalogging - EasyPhone -

FM/DAI - Cros/BiCros compatibility - T-Coil - Size 13 Battery.

Moderate/Severe hearing loss

Digital Super Power BTE - programmable 16 channels/7 programs.

Includes SoundRecover - UltraZoom Advanced-QuickSync -

WhistleBlock - NoiseBlock - Flex Volume - Zoom Control -

UserPreference - Tinnitus Balance- WindBlock WaterResistant -

Datalogging - EasyPhone - FM/DAI - Cros/BiCros compatibility - T-

Coil - Size 675 Battery. Moderate/Severe hearing loss

Digital BTE - programmable 16 channels/7 programs. Includes

SoundRecover2 - UltraZoom Advanced-QuickSync - WhistleBlock -

NoiseBlock - Flex Volume - Zoom Control - UserPreference - Tinnitus

Balance- WindBlock WaterResistant - Datalogging - EasyPhone -

FM/DAI - Cros/BiCros compatibility - T-Coil - Size13 Battery.

Moderate/Severe hearing loss

Digital Super Power BTE - programmable 12 channels/4 programs.

Includes SoundRecover2 - UltraZoom Advanced-QuickSync -

WhistleBlock - NoiseBlock - Flex Volume - Zoom Control -

UserPreference - Tinnitus Balance- WindBlock WaterResistant -

Datalogging - DuoPhone - FM/DAI - Cros/BiCros compatibility - T-

Coil -Size 675 Battery. Moderate/Severe hearing loss

Digital Super Power BTE - programmable 12 channels/4 programs.

Includes SoundRecover2 - UltraZoom -QuickSync - WhistleBlock -

NoiseBlock - Tinnitus Balance WaterResistant - Datalogging -

DuoPhone - FM/DAI - Cros/BiCros compatibility - Size 13 Battery.

Moderate/Severe hearing loss

Exhibit A - Sonova Phonak - Contract No. 129975 Amendment No. 4 12 of 25

Page 13: EQUIPMENT EQUIPMENT PERCENT FIXED NON - …...XXdB Max Gain/1XX dB Max Output V5261 Binaural $3,398.00 55.915% $1,498.00 $258.00 12 36 Audeo M50-13T Phonak 050-0517-H0 V5257 Monaural

Price Schedule

DESCRIPTION & FEATURES (See below) db RANGEMANUFA

CTURER

MODEL NUMBER (19

Characters or less)HCPCS CODE(S)

EQUIPMENT

PUBLISHED

LIST PRICE

EQUIPMENT PERCENT

DISCOUNT OFF LIST

PRICE

EQUIPMENT TOTAL

PRICE

FIXED NON -

WARRANTY REPAIR

PRICE

NON - WARRANTY

REPAIR PERIOD

(MONTHS)

WARRANTY REPAIR PERIOD

(MONTHS)

CROS II 312 - BTE Venture Package 30 level (BiCROS) Phonak 050-0228-01.30

V5221 $1,378.00 50.798% $678.00 $110.00 12 24

60db Max Gain - 122

CROS II 13 - BTE Venture Package 30 level Phonak 050-0229.01.30V5181 $1,378.00 50.798% $678.00 $110.00 12 24

63db Max Gain - 133

Max Output

CROS II 13 - BTE Venture Package 30 level (BiCROS) Phonak 050-0229.01.30V5221 $1,378.00 50.798% $678.00 $110.00 12 24

63db Max Gain - 133

Max Output

CROS II 312 - BTE Venture Package 50 level Phonak 050-0228-01.50V5181 $1,548.00 50.646% $764.00 $110.00 12 24

60db Max Gain - 122

Max Output

CROS II 312 - BTE Venture Package 50 level (BiCROS) Phonak 050-0228-01.50V5221 $1,548.00 50.646% $764.00 $110.00 12 24

60db Max Gain - 122

Max Output

CROS II 13 - BTE Venture Package 50 level Phonak 050-0229-01.50V5181 $1,548.00 50.646% $764.00 $110.00 12 24

63db Max Gain - 133

Max Output

CROS II 13 - BTE Venture Package 50 level (BiCROS) Phonak 050-0229-01.50V5221 $1,548.00 50.646% $764.00 $110.00 12 24

63db Max Gain - 133

Max Output

CROS II 312 - BTE Venture Package 70 level Phonak 050-0228-01.70V5181 $2,098.00 48.618% $1,078.00 $110.00 12 24

60db Max Gain - 122

CROS II 312 - BTE Venture Package 70 level (BiCROS) Phonak 050-0228-01.70V5221 $2,098.00 48.618% $1,078.00 $110.00 12 24

60db Max Gain - 122

CROS II 13 - BTE Venture Package 70 level Phonak 050-0229-01.70V5181 $2,098.00 48.618% $1,078.00 $110.00 12 24

63db Max Gain - 133

CROS II 13 - BTE Venture Package 70 level (BiCROS) Phonak 050-0229-01.70V5221 $2,098.00 48.618% $1,078.00 $110.00 12 24

63db Max Gain - 133 Designed for those with Bilateral hearing loss. Transfers the

microphone input signal to any model of Phonak Audéo V and Bolero

V

Designed for those with Unilateral hearing loss. Transfers the

microphone input signal to any model of Phonak Audéo V and Bolero

V

Designed for those with Bilateral hearing loss. Transfers the

microphone input signal to any model of Phonak Audéo V and Bolero

V

Designed for those with Bilateral hearing loss. Transfers the

microphone input signal to any model of Phonak Audéo V and Bolero

V

Designed for those with Unilateral hearing loss. Transfers the

microphone input signal to any model of Phonak Audéo V and Bolero

V

Designed for those with Unilateral hearing loss. Transfers the

microphone input signal to any model of Phonak Audéo V and Bolero

V

Designed for those with Unilateral hearing loss. Transfers the

microphone input signal to any model of Phonak Audéo V and Bolero

V

Designed for those with Unilateral hearing loss. Transfers the

microphone input signal to any model of Phonak Audéo V and Bolero

V

Designed for those with Bilateral hearing loss. Transfers the

microphone input signal to any model of Phonak Audéo V and Bolero

V

Designed for those with Bilateral hearing loss. Transfers the

microphone input signal to any model of Phonak Audéo V and Bolero

V

Designed for those with Bilateral hearing loss. Transfers the

microphone input signal to any model of Phonak Audéo V and Bolero

V

Exhibit A - Sonova Phonak - Contract No. 129975 Amendment No. 4 13 of 25

Page 14: EQUIPMENT EQUIPMENT PERCENT FIXED NON - …...XXdB Max Gain/1XX dB Max Output V5261 Binaural $3,398.00 55.915% $1,498.00 $258.00 12 36 Audeo M50-13T Phonak 050-0517-H0 V5257 Monaural

Price Schedule

IN THE EAR TYPES – Prices shall be for a single hearing aid or two hearing aids and case. List model number for the full range of instruments. Include all features. Indicate Class D power or Class B power.

FULL SHELL CONCHA MODEL DESCRIPTION &

FEATURES (See below)db RANGE MANUFACTURER

MODEL

NUMBER (19

Characters or

less)

HCPCS CODE(S)

EQUIPMENT

PUBLISHED

LIST PRICE

EQUIPMENT

PERCENT

DISCOUNT

OFF LIST

PRICE

EQUIPMENT

TOTAL PRICE

FIXED NON -

WARRANTY

REPAIR PRICE

NON -

WARRANTY

REPAIR

PERIOD

(MONTHS)

WARRANTY

REPAIR PERIOD

(MONTHS)

Virto B70-13 Phonak 063-0237-01 V5256 Monaural $1,399.00 50.036% $699.00 $129.00 12 36

V5260 Binaural $2,798.00 50.036% $1,398.00 $258.00 12 36

Virto B50 - 13 Phonak 063-0238-01 V5256 Monaural $839.00 54.112% $385.00 $129.00 12 36

V5260 Binaural $1,678.00 54.112% $770.00 $258.00 12 36

70db Max Gain -

130 Max Output

Virto B30-13 Phonak 063-0239-01 V5256 Monaural $649.00 53.929% $299.00 $129.00 12 36

V5260 Binaural $1,298.00 53.929% $598.00 $258.00 12 36

Virto V70-13 Phonak 063-0147-01 V5256 Monaural $1,349.00 48.184% $699.00 $129.00 12 36

V5260 Binaural $2,698.00 48.184% $1,398.00 $258.00 12 36

Virto V50-13 Phonak 063-0154-01 V5256 Monaural $799.00 51.815% $385.00 $129.00 12 36

V5260 Binaural $1,598.00 51.815% $770.00 $258.00 12 36

Virto V30-13 Phonak 063-0158-01 V5256 Monaural $629.00 52.464% $299.00 $129.00 12 36

V5260 Binaural $1,258.00 52.464% $598.00 $258.00 12 36

CROS II 13 -Venture ITE Package 70 level Phonak 063-0099-01.70 V5171 $2,098.00 48.618% $1,078.00 $110.00 12 24

CROS II 13 -Venture ITE Package 70 level (BiCROS) Phonak 063-0099-01.70 V5211 $2,098.00 48.618% $1,078.00 $110.00 12 24

CROS II 13 -Venture ITE Package 50 level Phonak 063-0099-01.50 V5171 $1,548.00 50.646% $764.00 $110.00 12 24

Designed for those with Bilateral hearing loss. Transfers the

microphone input signal to Phonak Virto V hearing aids

70db Max Gain -

130 Max Output

Digital Power Full shell 16 Channels/4 programs - Includes

SoundRecover2 - Sound Relax-Auto Sense OS- Music- Wind

Block- Speech in 360- Speech in Loud Noise- DuoPhone- Real

Ear Sound- Flex Control- Tinnitus Balance-Noise Block-

QuickSync - WhistleBlock - WaterResistant - Datalogging-

Cros B Compatibility -Size13 Battery. Moderate/Severe hearing

loss

70db Max Gain -

130 Max Output

Digital Full shell- programmable 12 channels/3 Programs.

Includes SoundRecover2-Real Ear Sound- DuoPhone-

QuickSync - WhistleBlock - NoiseBlock - Flex Control- Tinnitus

Balance-Cros B Compatible-Datalogging- Moderate/Severe

hearing loss

Digital Full shell 8 Channels/2 Programs- Includes AutoSense

OS- Tinnitus Balance- Sound Recover2- Noise Block- Quick

Sync- Whistle Block- Cros B Compatible -WaterResistant -

Datalogging - Size 312 Battery. Moderate/Severe hearing loss

70db Max Gain -

130 Max Output

Designed for those with Unilateral hearing loss. Transfers the

microphone input signal to Phonak Virto V hearing aids

Designed for those with Unilateral hearing loss. Transfers the

microphone input signal to Phonak Virto V hearing aids

70db Max Gain -

130 Max Output

70db Max Gain -

130 Max Output

Digital ITE, Programmable 16 channels/7 programs,AutoSense

OS, WhistleBlock, NoiseBlock, Sound Relax, Duo Phone, Flex

Control, Quick Sync, SoundRecover, Tinnitus Balance, auto

Acclimatization, UltraZoom Essential, 16 channels, WCP

compatible, size 13 battery, Roger compatible, telecoil

70db Max Gain -

130 Max Output

Digital ITE, 12 channels/4 programs,AutoSense OS, SNR-

Boost, FlexControl, Flex Volume, DuoPhone, Real Ear Sound,

WhistleBlock, NoiseBlock, Quick Sync, SoundRecover,

Tinnitus Balance, auto Acclimatization, UltraZoom Standard,

12 channels, WCP compatible, size 13 battery, telecoil, Roger

compatible

70db Max Gain -

130 Max Output

Digital ITE AutoSense OS, WhistleBlock, NoiseBlock, Quick

Sync, SoundRecover, Tinnitus Balance, auto Acclimatization,

UltraZoom Essential, 8 channels, WCP compatible, size 13

battery, Roger compatible, telecoil

70db Max Gain -

130 Max Output

Exhibit A - Sonova Phonak - Contract No. 129975 Amendment No. 4 14 of 25

Page 15: EQUIPMENT EQUIPMENT PERCENT FIXED NON - …...XXdB Max Gain/1XX dB Max Output V5261 Binaural $3,398.00 55.915% $1,498.00 $258.00 12 36 Audeo M50-13T Phonak 050-0517-H0 V5257 Monaural

Price Schedule

FULL SHELL CONCHA MODEL DESCRIPTION &

FEATURES (See below)db RANGE MANUFACTURER

MODEL

NUMBER (19

Characters or

less)

HCPCS CODE(S)

EQUIPMENT

PUBLISHED

LIST PRICE

EQUIPMENT

PERCENT

DISCOUNT

OFF LIST

PRICE

EQUIPMENT

TOTAL PRICE

FIXED NON -

WARRANTY

REPAIR PRICE

NON -

WARRANTY

REPAIR

PERIOD

(MONTHS)

WARRANTY

REPAIR PERIOD

(MONTHS)

CROS II 13 -Venture ITE Package 50 level (BiCROS) Phonak 063-0099-01.50 V5211 $1,548.00 50.646% $764.00 $110.00 12 24

CROS II 13 -Venture ITE Package 30 level Phonak 063-0099-01.30 V5171 $1,378.00 50.798% $678.00 $110.00 12 24

CROS II 13 -Venture ITE Package 30 level (BiCROS) Phonak 063-0099-01.30 V5211 $1,378.00 50.798% $678.00 $110.00 12 24

CROS B Custom 13- 30 level Belong VirtoPhonak

063-0247-01.30 V5171 $1,398.00 51.502% $678.00 $110.00 12 24

Designed for those with Unilateral hearing loss. Transfers the

microphone input signal to any model of Phonak Belong Virto

63 dB Max Gain -

122 Output

CROS B Custom 13- 30 level Belong Virto (BiCROS)

Phonak

063-0247-01.30 V5211 $1,398.00 51.502% $678.00 $110.00 12 24

Designed for those with Bilateral hearing loss. Transfers the

microphone input signal to any model of Phonak Belong Virto

63 dB Max Gain -

122 Output

CROS B Custom 13 - 50 level Belong Virto Phonak 063-0247-01.50 V5171 $1,588.00 51.889% $764.00 $110.00 12 24

CROS B Custom 13 - 50 level Belong Virto (BiCROS) Phonak 063-0247-01.50 V5211 $1,588.00 51.889% $764.00 $110.00 12 24

CROS B Custom 13 - 70 level Belong Virto Phonak 063-0247-01.70 V5171 $2,148.00 49.814% $1,078.00 $110.00 12 24

CROS B Custom 13 - 70 level Belong Virto (BiCROS) Phonak 063-0247-01.70 V5211 $2,148.00 49.814% $1,078.00 $110.00 12 24

Designed for those with Bilateral hearing loss. Transfers the

microphone input signal to any model of Phonak Belong Virto

63db Max Gain -

133 Max Output

Designed for those with Bilateral hearing loss. Transfers the

microphone input signal to any model of Phonak Belong Virto

63db Max Gain -

133 Max Output

Designed for those with Bilateral hearing loss. Transfers the

microphone input signal to Phonak Virto V hearing aids

70db Max Gain -

130 Max Output

Designed for those with Bilateral hearing loss. Transfers the

microphone input signal to Phonak Virto V hearing aids

70db Max Gain -

130 Max Output

Designed for those with Unilateral hearing loss. Transfers the

microphone input signal to any model of Phonak Belong Virto

63db Max Gain -

133 Max Output

Designed for those with Unilateral hearing loss. Transfers the

microphone input signal to any model of Phonak Belong Virto

63db Max Gain -

133 Max Output

Designed for those with Unilateral hearing loss. Transfers the

microphone input signal to Phonak Virto V hearing aids

70db Max Gain -

130 Max Output

Exhibit A - Sonova Phonak - Contract No. 129975 Amendment No. 4 15 of 25

Page 16: EQUIPMENT EQUIPMENT PERCENT FIXED NON - …...XXdB Max Gain/1XX dB Max Output V5261 Binaural $3,398.00 55.915% $1,498.00 $258.00 12 36 Audeo M50-13T Phonak 050-0517-H0 V5257 Monaural

Price Schedule

IN THE EAR TYPES – Prices shall be for a single hearing aid, or two hearing aids and case. List model number for the full range of instruments. Include all features. Indicate Class D power or Class B power.

HALF SHELL CONCHA DESCRIPTION & FEATURES

(See below)db RANGE

MANUFACT

URER

MODEL NUMBER

(19 Characters or

less)

HCPCS CODE(S)

EQUIPMENT

PUBLISHED

LIST PRICE

EQUIPMENT

PERCENT

DISCOUNT OFF

LIST PRICE

EQUIPMENT

TOTAL PRICE

FIXED NON -

WARRANTY

REPAIR PRICE

NON -

WARRANTY

REPAIR PERIOD

(MONTHS)

WARRANTY

REPAIR PERIOD

(MONTHS)

Virto B70 312

65dB 122 Max

OutputPhonak 063-0024-01

V5256 Monaural $1,399.00 50.036% $699.00 $129.00 12 36

V5260 Binaural $2,798.00 50.036% $1,398.00 $258.00 12 36

Virto B50 312

70db Max Gain -

130 Max OutputPhonak 063-0234-01

V5256 Monaural $839.00 54.112% $385.00 $129.00 12 36

V5260 Binaural $1,678.00 54.112% $770.00 $258.00 12 36

Virto B30 312Phonak 063-0235-01

V5256 Monaural $649.00 53.929% $299.00 $129.00 12 36

70db Max Gain -

130 Max Output V5260 Binaural $1,298.00 53.929% $598.00 $258.00 12 36

Virto V30-312 Phonak 063-0157-01 V5256 Monaural $629.00 52.464% $299.00 $129.00 12 36

V5260 Binaural $1,258.00 52.464% $598.00 $258.00 12 36

Virto V50-312 Phonak 063-0153-01 V5256 Monaural $799.00 51.815% $385.00 $129.00 12 36

V5260 Binaural $1,598.00 51.815% $770.00 $258.00 12 36

Virto V70-312 Phonak 063-0146-01 V5256 Monaural $1,349.00 48.184% $699.00 $129.00 12 36

V5260 Binaural $2,698.00 48.184% $1,398.00 $258.00 12 36

Digital Power Half Shell 16 Channels/4 programs - Includes

SoundRecover2 - Sound Relax-Auto Sense OS- Music- Wind

Block- Speech in 360- Speech in Loud Noise- DuoPhone- Real

Ear Sound- Flex Control- Tinnitus Balance-Noise Block-

QuickSync - WhistleBlock - WaterResistant - Datalogging- Cros

B Compatibility - Size 312 Battery. Moderate/Severe hearing loss

Digital Half shell- programmable 12 channels/3 Programs.

Includes SoundRecover2-Real Ear Sound- DuoPhone-

QuickSync - WhistleBlock - NoiseBlock - Flex Control- Tinnitus

Balance-Cros B Compatible-Datalogging- Moderate/Severe

hearing loss

Digital Half shell 8 Channels/2 Programs- Includes AutoSense

OS- Tinnitus Balance- Sound Recover2- Noise Block- Quick

Sync- Whistle Block- Cros B Compatible -WaterResistant -

Datalogging - Wind/Weather Protection - Size 312 Battery.

Moderate/Severe hearing loss

Digital Half Shell,AutoSense OS, WhistleBlock, NoiseBlock,

Quick Sync, SoundRecover, Tinnitus Balance, auto

Acclimatization, UltraZoom Essential, 8 channels, WCP

compatible, size 312 battery, Roger compatible, telecoil

60db Max Gain -

122 Max Output

Digital Half Shell, AutoSense OS, SNR-Boost, FlexControl, Flex

Volume, DuoPhone, Real Ear Sound, WhistleBlock, NoiseBlock,

Quick Sync, SoundRecover, Tinnitus Balance, auto

Acclimatization, UltraZoom Standard, 12 channels, WCP

compatible, size 312 battery, telecoil, Roger compatible

60db Max Gain -

122 Max Output

Digital Half Shell,AutoSense OS, WhistleBlock, NoiseBlock,

Quick Sync, SoundRecover, Tinnitus Balance, auto

Acclimatization, UltraZoom Essential, 8 channels, WCP

compatible, size 312 battery, Roger compatible, telecoil

60db Max Gain -

122 Max Output

Exhibit A - Sonova Phonak - Contract No. 129975 Amendment No. 4 16 of 25

Page 17: EQUIPMENT EQUIPMENT PERCENT FIXED NON - …...XXdB Max Gain/1XX dB Max Output V5261 Binaural $3,398.00 55.915% $1,498.00 $258.00 12 36 Audeo M50-13T Phonak 050-0517-H0 V5257 Monaural

Price Schedule

HALF SHELL CONCHA DESCRIPTION & FEATURES

(See below)db RANGE

MANUFACT

URER

MODEL NUMBER

(19 Characters or

less)

HCPCS CODE(S)

EQUIPMENT

PUBLISHED

LIST PRICE

EQUIPMENT

PERCENT

DISCOUNT OFF

LIST PRICE

EQUIPMENT

TOTAL PRICE

FIXED NON -

WARRANTY

REPAIR PRICE

NON -

WARRANTY

REPAIR PERIOD

(MONTHS)

WARRANTY

REPAIR PERIOD

(MONTHS)

CROS II 312 -Venture ITE Package 70 level Phonak 063-0098-01.70 V5171 $2,098.00 48.618% $1,078.00 $110.00 12 24

CROS II 312 -Venture ITE Package 70 level (BiCROS) Phonak 063-0098-01.70 V5211 $2,098.00 48.618% $1,078.00 $110.00 12 24

CROS II 312 -Venture ITE Package 50 level Phonak 063-0098-01.50 V5171 $1,548.00 50.646% $764.00 $110.00 12 24

CROS II 312 -Venture ITE Package 50 level (BiCROS) Phonak 063-0098-01.50 V5211 $1,548.00 50.646% $764.00 $110.00 12 24

CROS II 312 -Venture ITE Package 30 level Phonak 063-0098-01.30 V5171 $1,378.00 50.798% $678.00 $110.00 12 24

CROS II 312 -Venture ITE Package 30 level (BiCROS) Phonak 063-0098-01.30 V5211 $1,378.00 50.798% $678.00 $110.00 12 24

CROS B Custom 312- 30 level Virto Belong Phonak 063-0246-01.30 V5171 $1,398.00 51.502% $678.00 $110.00 12 24

Designed for those with Unilateral hearing loss. Transfers the

microphone input signal to any model of Phonak Virto Belong

63 dB Max Gain -

122 Output

CROS B Custom 312- 30 level Virto Belong (BiCROS) Phonak 063-0246-01.30 V5211 $1,398.00 51.502% $678.00 $110.00 12 24

Designed for those with Bilateral hearing loss. Transfers the

microphone input signal to any model of Phonak Virto Belong

63 dB Max Gain -

122 Output

CROS B Custom 312 - 50 level Virto Belong Phonak 063-0246-01.50 V5171 $1,588.00 51.889% $764.00 $110.00 12 24

CROS B Custom 312 - 50 level Virto Belong (BiCROS) Phonak 063-0246-01.50 V5211 $1,588.00 51.889% $764.00 $110.00 12 24

CROS B Custom 312 -70 Virto Belong Phonak 063-0246-01.70 V5171 $2,148.00 49.814% $1,078.00 $110.00 12 24

CROS B Custom 312 -70 Virto Belong (BiCROS) Phonak 063-0246-01.70 V5211 $2,148.00 49.814% $1,078.00 $110.00 12 24

Designed for those with Bilateral hearing loss. Transfers the

microphone input signal to Phonak Virto V hearing aids

70db Max Gain -

130 Max Output

Designed for those with Bilateral hearing loss. Transfers the

microphone input signal to Phonak Virto V hearing aids

70db Max Gain -

130 Max Output

Designed for those with Unilateral hearing loss. Transfers the

microphone input signal to Phonak Virto V hearing aids

70db Max Gain -

130 Max Output

Designed for those with Bilateral hearing loss. Transfers the

microphone input signal to any model of Phonak Virto Belong

63db Max Gain -

133 Max Output

Designed for those with Bilateral hearing loss. Transfers the

microphone input signal to any model of Phonak Virto Belong

63db Max Gain -

133 Max Output

Designed for those with Unilateral hearing loss. Transfers the

microphone input signal to Phonak Virto V hearing aids

70db Max Gain -

130 Max Output

Designed for those with Unilateral hearing loss. Transfers the

microphone input signal to any model of Phonak Virto Belong

63db Max Gain -

133 Max Output

Designed for those with Unilateral hearing loss. Transfers the

microphone input signal to any model of Phonak Virto Belong

63db Max Gain -

133 Max Output

Designed for those with Unilateral hearing loss. Transfers the

microphone input signal to Phonak Virto V hearing aids

70db Max Gain -

130 Max Output

Designed for those with Unilateral hearing loss. Transfers the

microphone input signal to Phonak Virto V hearing aids

70db Max Gain -

130 Max Output

Exhibit A - Sonova Phonak - Contract No. 129975 Amendment No. 4 17 of 25

Page 18: EQUIPMENT EQUIPMENT PERCENT FIXED NON - …...XXdB Max Gain/1XX dB Max Output V5261 Binaural $3,398.00 55.915% $1,498.00 $258.00 12 36 Audeo M50-13T Phonak 050-0517-H0 V5257 Monaural

Price Schedule

IN THE EAR TYPES – Prices shall be for a single hearing aid or two hearing aids and case. List model number for the full range of instruments. Include all features. Indicate Class D power or Class B power.

LOW PROFILE DESCRIPTION &

FEATURES (See below)db RANGE

MANUFACTUR

ER

MODEL

NUMBER (19

Characters or

less)

HCPCS CODE(S)

EQUIPMENT

PUBLISHED

LIST PRICE

EQUIPMENT

PERCENT

DISCOUNT

OFF LIST

PRICE

EQUIPMENT

TOTAL PRICE

FIXED NON -

WARRANTY

REPAIR PRICE

NON -

WARRANTY

REPAIR

PERIOD

(MONTHS)

WARRANTY

REPAIR PERIOD

(MONTHS)

Virto B70 - Low Profile MC Phonak 063-0217-01 V5256 Monaural $1,399.00 50.036% $699.00 $129.00 12 36

V5260 Binaural $2,798.00 50.036% $1,398.00 $258.00 12 36

60db Max Gain -

122 Max Output

Virto B50 - Low Profile MC Phonak 063-0218-01 V5256 Monaural $839.00 54.112% $385.00 $129.00 12 36

V5260 Binaural $1,678.00 54.112% $770.00 $258.00 12 36

60db Max Gain -

122 Max Output

Virto B30-10 Low Profile MC Phonak 063-0219-01 V5256 Monaural $649.00 53.929% $299.00 $129.00 12 36

V5260 Binaural $1,298.00 53.929% $598.00 $258.00 12 36

60db Max Gain -

122 Max Output

Digital ITE - programmable 16

channels/7 programs. Includes

SoundRecover2 -Speech in 360-Sound

Relax-Wind Block-Flex Control-Tinnitus

Balance Noise Generator- UltraZoom

Advanced-WhistleBlock - NoiseBlock -

Quick Sync - Zoom Control -

UserPreference - Tinnitus Balance-

WindBlock WaterResistant - Datalogging-

Size10 Battery. Mild/Moderate hearing

loss

Digital ITE - programmable 12

channels/4 programs. Includes

SoundRecover2 - Sound Relax-Real Ear

Sound-Flex Control-Tinnitus Balance

Generator-Noise Block-Quick Sync-

Whistle Block-UltraZoom Advanced-

WhistleBlock - NoiseBlock - Flex Volume

- Zoom Control - UserPreference -

Tinnitus Balance- WindBlock

WaterResistant - Datalogging- Size10

Battery. Mild/Moderate hearing loss

Digital ITE - programmable 8

channels/4 programs. Includes

SoundRecover2 - Sound Relax-Flex

Control-Tinnitus Balance Generator-

Quick Sync-WhistleBlock -

NoiseBlock- UserPreference -

Tinnitus Balance- WindBlock

WaterResistant - Datalogging-

Size10 Battery. Mild/Moderate

hearing loss

Exhibit A - Sonova Phonak - Contract No. 129975 Amendment No. 4 18 of 25

Page 19: EQUIPMENT EQUIPMENT PERCENT FIXED NON - …...XXdB Max Gain/1XX dB Max Output V5261 Binaural $3,398.00 55.915% $1,498.00 $258.00 12 36 Audeo M50-13T Phonak 050-0517-H0 V5257 Monaural

Price Schedule

LOW PROFILE DESCRIPTION &

FEATURES (See below)db RANGE

MANUFACTUR

ER

MODEL

NUMBER (19

Characters or

less)

HCPCS CODE(S)

EQUIPMENT

PUBLISHED

LIST PRICE

EQUIPMENT

PERCENT

DISCOUNT

OFF LIST

PRICE

EQUIPMENT

TOTAL PRICE

FIXED NON -

WARRANTY

REPAIR PRICE

NON -

WARRANTY

REPAIR

PERIOD

(MONTHS)

WARRANTY

REPAIR PERIOD

(MONTHS)

Virto V70 - Low Profile MC Phonak 063-0145-01V5256 Monaural $1,349.00 48.184% $699.00 $129.00 12 36

V5260 Binaural $2,698.00 48.184% $1,398.00 $258.00 12 36

Virto V50 - Low Profile MC Phonak 063-0152-01 V5256 Monaural $799.00 51.815% $385.00 $129.00 12 36

V5260 Binaural $1,598.00 51.815% $770.00 $258.00 12 36

Virto V30 - Low Profile MC Phonak 063-0177-01 V5256 Monaural $629.00 52.464% $299.00 $129.00 12 36

V5260 Binaural $1,258.00 52.464% $598.00 $258.00 12 36

60db Max Gain -

122 Max Output

60db Max Gain -

122 Max Output

Digital ITE - programmable 8 channels/4

programs. Includes SoundRecover - Flex

Control-Tinnitus Balance Generator-

Noise Block-Quick Sync-WhistleBlock -

NoiseBlock- UserPreference - Tinnitus

Balance- WindBlock WaterResistant -

Datalogging- Size10 Battery.

Mild/Moderate hearing loss

Digital ITE - programmable 16

channels/7 programs. Includes

SoundRecover2 -Speech in 360-Sound

Relax-Wind Block-Flex Control-Tinnitus

Balance Noise Generator- UltraZoom

Advanced-WhistleBlock - NoiseBlock -

Quick Sync - Zoom Control -

UserPreference - Tinnitus Balance-

WindBlock WaterResistant - Datalogging-

Size10 Battery. Mild/Moderate hearing

loss

Digital ITE - programmable 16

channels/7 programs. Includes

SoundRecover -Wind Block-Flex Control-

Tinnitus Balance Noise Generator-

UltraZoom Advanced-WhistleBlock -

NoiseBlock - DuoPhone-Quick Sync -

Zoom Control - UserPreference - Tinnitus

Balance- WindBlock WaterResistant -

Datalogging- Size10 Battery.

Mild/Moderate hearing loss

60db Max Gain -

122 Max Output

Exhibit A - Sonova Phonak - Contract No. 129975 Amendment No. 4 19 of 25

Page 20: EQUIPMENT EQUIPMENT PERCENT FIXED NON - …...XXdB Max Gain/1XX dB Max Output V5261 Binaural $3,398.00 55.915% $1,498.00 $258.00 12 36 Audeo M50-13T Phonak 050-0517-H0 V5257 Monaural

Price Schedule

Personal Frequency Modulations (FM) Systems – Prices shall be for either a single instrument or complete FM system with antenna type built into the microphone cords, which may be powered by disposable alkaline

batteries or rechargeable batteries.

PFM (FM) Systems DESCRIPTION & FEATURES (See

below)

db

RANGE

MANUFAC

TURER

MODEL NUMBER (19

Characters or less)

HCPCS

CODE(S)

EQUIPMENT

PUBLISHED

LIST PRICE

EQUIPMENT

PERCENT

DISCOUNT

OFF LIST

PRICE

EQUIPMENT

TOTAL PRICE

FIXED NON -

WARRANTY

REPAIR PRICE

NON -

WARRANTY

REPAIR

PERIOD

(MONTHS)

WARRANTY REPAIR

PERIOD (MONTHS)

Roger Adult Monaural Phonak FM_ADULT_MON V5281

Kit contains 1 Roger Transmitter/Microphone and 1

Roger Receiver N/A As indicated by components per Cheryl

Roger Pediatric Monaural Phonak FM_PED_MON V5281

Kit contains 1 Roger Pediatric Transmitter/Microphone

and 1 Roger Receiver N/A

Roger Adult Binaural Phonak FM_ADULT_BIN V5282

Kit contains 1 Roger Transmitter/Microphone and 2

Roger Receivers N/A

Roger Pediatric Binaural Phonak FM_PED_BIN V5282

Kit contains 1 Roger Pediatric Transmitter/Microphone

and 2 Roger Receivers N/A

Roger Select IN Phonak 056-3002-P5011 V5288 $1,399.00 35.000% $909.35 $110.00 12 24

Roger Select IN is a wireless microphone that when

placed on the table can automatically selects who is

talking and seamlessly switches from one talker to

another. It can also transmit multimedia and Bluetooth

phone calls. Compatible with Roger Direct N/A

Roger Table Microphone II IN Phonak 056-4002-P5011 V5288 $1,799.00 35.000% $1,169.35 $110.00 12 24

Wireless microphone especially designed for meetings.

Simply place them on the meeting table and speech is

clearly and wirelessly transmitted to your receivers.

Compatible with Roger Direct N/A

Roger Pen IN Phonak 056-3003-P90008 V5288 $1,349.00 35.000% $876.85 $110.00 12 24

N/A `

As indicated by components per Cheryl

As indicated by components per Cheryl

As indicated by components per Cheryl

Roger technology is an adaptive digital wireless

transmission technology. Roger Pen features adaptive

wireless transmission, fully automated settings,

wideband audio Bluetooth for cell phone use, TV

connectivity and an audio input for listening to

multimedia. Compatible with Roger DIrect

Exhibit A - Sonova Phonak - Contract No. 129975 Amendment No. 4 20 of 25

Page 21: EQUIPMENT EQUIPMENT PERCENT FIXED NON - …...XXdB Max Gain/1XX dB Max Output V5261 Binaural $3,398.00 55.915% $1,498.00 $258.00 12 36 Audeo M50-13T Phonak 050-0517-H0 V5257 Monaural

Price Schedule

PFM (FM) Systems DESCRIPTION & FEATURES (See

below)

db

RANGE

MANUFAC

TURER

MODEL NUMBER (19

Characters or less)

HCPCS

CODE(S)

EQUIPMENT

PUBLISHED

LIST PRICE

EQUIPMENT

PERCENT

DISCOUNT

OFF LIST

PRICE

EQUIPMENT

TOTAL PRICE

FIXED NON -

WARRANTY

REPAIR PRICE

NON -

WARRANTY

REPAIR

PERIOD

(MONTHS)

WARRANTY REPAIR

PERIOD (MONTHS)

Roger Select Phonak 052-3477-000XX V5288 $900.00 35.000% $585.00 $110.00 12 12

Roger Select is a wireless microphone that when placed

on the table can automatically selects who is talking and

seamlessly switches from one talker to another. It can

also transmit multimedia and Bluetooth phone calls.

Compatible with Roger 02 and 03 receivers. N/A

Roger Table Microphone II Phonak 052-4125-000P5 V5288 $1,300.00 35.000% $845.00 $110.00 12 12

Wireless microphone especially designed for meetings.

Simply place them on the meeting table and speech is

clearly and wirelessly transmitted to your receivers.

Compatible with Roger 02 and 03 receivers. N/A

TV Connector D Phonak 076-3006-0611 V5286 $199.00 25.000% $149.25 $110.00 12 12

Interface allows you to stream the TV signal directly to

your Audeo M hearing instruments N/A

Roger Easy Pen-Transmitter Phonak 052-3285-000XX V5288 $775.00 35.000% $503.75 $110.00 12 12

N/A

Roger Pen-Transmitter Phonak 052-3191-000XX V5288 $825.00 35.000% $536.25 $110.00 12 12

N/A

Roger Clip-On Mic-TransmitterPhonak

052-3294V5288 $640.00 35.000% $416.00 $110.00 12 12

N/A

Roger technology is an adaptive digital wireless

transmission technology. Roger Easy Pen features

adaptive wireless transmission, fully automated settings,

wideband audio for TV connectivity and an audio input

for listening to multimedia. Kit includes: Power supply

and docking station. Compatible with Roger 02 and 03

receivers

Roger technology is an adaptive digital wireless

transmission technology. Roger Pen features adaptive

wireless transmission, fully automated settings,

wideband audio Bluetooth for cell phone use, TV

connectivity and an audio input for listening to

multimedia. Kit includes: Power supply and docking

station. Compatible with Roger 02 and 03 receivers

Roger technology is an adaptive digital wireless

transmission technology. Roger Clip-On Mic is a

discreet, shirt-worm microphone that uses adaptive

wireless transmission. Features an audio input for

listening to multimedia and TV connectivity. Kit includes:

Power supply and docking station. Compatible with

Roger 02 and 03 receivers

Exhibit A - Sonova Phonak - Contract No. 129975 Amendment No. 4 21 of 25

Page 22: EQUIPMENT EQUIPMENT PERCENT FIXED NON - …...XXdB Max Gain/1XX dB Max Output V5261 Binaural $3,398.00 55.915% $1,498.00 $258.00 12 36 Audeo M50-13T Phonak 050-0517-H0 V5257 Monaural

Price Schedule

PFM (FM) Systems DESCRIPTION & FEATURES (See

below)

db

RANGE

MANUFAC

TURER

MODEL NUMBER (19

Characters or less)

HCPCS

CODE(S)

EQUIPMENT

PUBLISHED

LIST PRICE

EQUIPMENT

PERCENT

DISCOUNT

OFF LIST

PRICE

EQUIPMENT

TOTAL PRICE

FIXED NON -

WARRANTY

REPAIR PRICE

NON -

WARRANTY

REPAIR

PERIOD

(MONTHS)

WARRANTY REPAIR

PERIOD (MONTHS)

Roger Touchscreen MicrophonePhonak

052-3297V5288 $995.00 35.000% $646.75 $110.00 12 12

Simple and intuitive microphone for the teacher to wear

around the neck or place on a table to pick up speech

from a group of students. Compatible with Roger 02

receivers N/A

Roger Pass-Around MicrophonePhonak

052-3261V5288 $550.00 35.000% $357.50 $110.00 12 24

N/A

Roger MyLink (02)-Pediatric-Receiver Phonak 052-0502 V5283 $699.00 35.000% $454.35 $110.00 12 24

N/A

Roger MyLink (02)-Pediatric Receiver (short loop) Phonak 052-0501 V5283 $699.00 35.000% $454.35 $110.00 12 24

N/A

Roger MyLink (03) Adult Receiver (includes charger) Phonak 052-0510 V5283 $600.00 35.000% $390.00 $110.00 12 24

N/A

Roger Technology.Universal Roger receiver that works

with any hearing aid or cochlear implant that features a

telecoil. Headphone output for listeners with normal

hearing. Includes power supply and 30 inch neckloop.

Compatible with Roger inspiro, Roger Pen, Roger

TableMic, Roger Clip-On Mic and Roger SoundField.

Roger Technology.Universal Roger receiver that works

with any hearing aid or cochlear implant that features a

telecoil. Headphone output for listeners with normal

hearing. Includes power supply and 22 inch neckloop.

Compatible with Roger inspiro, Roger Pen, Roger

TableMic, Roger Clip-On Mic and Roger SoundField.

Roger Technology.Universal Roger receiver that works

with any hearing aid or cochlear implant that features a

telecoil. Headphone output for listeners with normal

hearing. Includes power supply and 30 inch neckloop.

Compatible with Roger Pen, Roger TableMic, and Roger

Clip-On Mic.

Student microphone that can be passed from one

student to another, allowing the child with a hearing loss

to hear not only the teacher but also classmate

comments. Compatible with Roger 02 receivers

Exhibit A - Sonova Phonak - Contract No. 129975 Amendment No. 4 22 of 25

Page 23: EQUIPMENT EQUIPMENT PERCENT FIXED NON - …...XXdB Max Gain/1XX dB Max Output V5261 Binaural $3,398.00 55.915% $1,498.00 $258.00 12 36 Audeo M50-13T Phonak 050-0517-H0 V5257 Monaural

Price Schedule

PFM (FM) Systems DESCRIPTION & FEATURES (See

below)

db

RANGE

MANUFAC

TURER

MODEL NUMBER (19

Characters or less)

HCPCS

CODE(S)

EQUIPMENT

PUBLISHED

LIST PRICE

EQUIPMENT

PERCENT

DISCOUNT

OFF LIST

PRICE

EQUIPMENT

TOTAL PRICE

FIXED NON -

WARRANTY

REPAIR PRICE

NON -

WARRANTY

REPAIR

PERIOD

(MONTHS)

WARRANTY REPAIR

PERIOD (MONTHS)

Roger X (02) Pediatric Receiver Phonak 052-3113-D02P5 V5284 $926.00 35.000% $601.90 $110.00 12 24

N/A

Roger X (03) Adult Receiver Phonak 052-3215-D03P5 V5284 $740.00 35.000% $481.00 $110.00 12 24

N/A

Roger 14 (02) Pediatric Integrated Receiver Phonak 052-3222-D02XX V5273 $926.00 35.000% $601.90 $110.00 12 24

N/A

Roger 14 (03) Adult Integrated Receiver Phonak 052-3223-D03XX V5273 $740.00 35.000% $481.00 $110.00 12 24

N/A

Roger 17 (02) Pediatric Integrated Receiver Phonak 052-3235-D02XX V5273 $926.00 35.000% $601.90 $110.00 12 24

N/A

Roger 17 (03) Adult Integrated Receiver Phonak 052-3236-D03XX V5273 $740.00 35.000% $481.00 $110.00 12 24

N/A

Roger Technology. Discreet design integrated Roger

receivers for use with Advanced Bionics Naida CI.

Compatible with Roger Pen, Roger TableMic and Roger

Clip-On Mic

Roger Technology. Discreet design integrated Roger

receivers for use with Advanced Bionics Naida CI.

Compatible with Roger inspiro, Roger Pen, Roger

TableMic, Roger Clip-On Mic and Roger SoundField.

Roger Technology. Discreet design integrated Roger

receivers for use with Cochlear's Nucleus 5 and 6.

Compatible with Roger inspiro, Roger Pen, Roger

TableMic, Roger Clip-On Mic and Roger SoundField.

Roger Technology. Discreet design integrated Roger

receivers for use with Cochlear's Nucleus 5 and 6.

Compatible with Roger Pen, Roger TableMic, and Roger

Clip-On Mic

Roger Technology. Miniature universal Roger receiver-

compatible with most BTE hearing aids (with appropriate

audioshoe), cochlear implant speech processor, and

streaming device through the three pin Europlug

connector. Compatible with Roger Pen, Roger

TableMicand Roger Clip-On Mic

Roger Technology. Miniature universal Roger receiver-

compatible with most BTE hearing aids (with appropriate

audioshoe), cochlear implant speech processor, and

streaming device through the three pin Europlug

connector. Compatible with Roger inspiro, Roger Pen,

Roger TableMic, Roger Clip-On Mic and Roger

SoundField.

Exhibit A - Sonova Phonak - Contract No. 129975 Amendment No. 4 23 of 25

Page 24: EQUIPMENT EQUIPMENT PERCENT FIXED NON - …...XXdB Max Gain/1XX dB Max Output V5261 Binaural $3,398.00 55.915% $1,498.00 $258.00 12 36 Audeo M50-13T Phonak 050-0517-H0 V5257 Monaural

Price Schedule

PFM (FM) Systems DESCRIPTION & FEATURES (See

below)

db

RANGE

MANUFAC

TURER

MODEL NUMBER (19

Characters or less)

HCPCS

CODE(S)

EQUIPMENT

PUBLISHED

LIST PRICE

EQUIPMENT

PERCENT

DISCOUNT

OFF LIST

PRICE

EQUIPMENT

TOTAL PRICE

FIXED NON -

WARRANTY

REPAIR PRICE

NON -

WARRANTY

REPAIR

PERIOD

(MONTHS)

WARRANTY REPAIR

PERIOD (MONTHS)

Roger 18 Adult Phonak 052-3236-D03XX V5284 $740.00 35.000% $481.00 $110.00 12 24

Roger Technology. Discreet design integrated Roger

receivers. Compatible with Roger Pen, Roger TableMic

and Roger Clip-On Mic. Compatible with Audeo V-13,

Bolero V-P/SP, Naida V-RIC/SP, Sky V-RIC/P/SP N/A

Roger 18-Pediatric Phonak 052-3281-D02XX V5284 $926.00 35.000% $601.90 $110.00 12 24

Roger Technology. Discreet design integrated Roger

receivers. Compatible with Roger inspiro, Roger

SoundField, Roger Pen, Roger TableMic and Roger Clip-

On Mic. Compatible with Audeo V-13, Bolero V-P/SP,

Naida V-RIC/SP, Sky V-RIC/P/SP N/A

Roger 19-Adult Integrated ReceiverPhonak

052-3292-D03XXV5284 $740.00 35.000% $481.00 $110.00 12 24

Roger Technology. Discreet design integrated Roger

receivers. Compatible with Roger Pen, Roger TableMic

and Roger Clip-On Mic. Compatible with Naida V-UP and

Sky V-UP N/A

Roger 19-Pediatric Integrated Receiver Phonak 052-3291-D02XX V5284 $926.00 35.000% $601.90 $110.00 12 24

Roger Technology. Discreet design integrated Roger

receivers. Compatible with Roger inspiro, Roger

SoundField, Roger Pen, Roger TableMic and Roger Clip-

On Mic. Compatible with Naida V-UP and Sky V-UP N/A

Roger 20-Pediatric Integrated Receiver Phonak 052-3317-D02XX V5284 $926.00 35.000% $601.90 $110.00 12 24

Roger Technology. Discreet design integrated Roger

receivers. Compatible with Roger inspiro, Roger

SoundField, Roger Pen, Roger TableMic and Roger Clip-

On Mic. Compatible with Cochlear Nucleus 7 N/A

Roger 21-Pediatric Integrated Receiver Phonak 052-3469-D02XX V5284 $926.00 35.000% $601.90 $110.00 12 24

Roger Technology. Discreet design integrated Roger

receivers. Compatible with Roger inspiro, Roger

SoundField, Roger Pen, Roger TableMic and Roger Clip-

On Mic. Compatible with MED-EL Sonnet N/A

Roger Focus (02) Receiver Phonak 052-3272-D02XX V5284 $750.00 35.000% $487.50 $110.00 12 24

N/A

Roger Technology. Stand-Alone Roger receiver

designed for those with normal hearing/APD. Compatible

with Roger inspiro, Roger Pen, Roger Clip-On Mic and

Roger SoundField.

Exhibit A - Sonova Phonak - Contract No. 129975 Amendment No. 4 24 of 25

Page 25: EQUIPMENT EQUIPMENT PERCENT FIXED NON - …...XXdB Max Gain/1XX dB Max Output V5261 Binaural $3,398.00 55.915% $1,498.00 $258.00 12 36 Audeo M50-13T Phonak 050-0517-H0 V5257 Monaural

Price Schedule

PFM (FM) Systems DESCRIPTION & FEATURES (See

below)

db

RANGE

MANUFAC

TURER

MODEL NUMBER (19

Characters or less)

HCPCS

CODE(S)

EQUIPMENT

PUBLISHED

LIST PRICE

EQUIPMENT

PERCENT

DISCOUNT

OFF LIST

PRICE

EQUIPMENT

TOTAL PRICE

FIXED NON -

WARRANTY

REPAIR PRICE

NON -

WARRANTY

REPAIR

PERIOD

(MONTHS)

WARRANTY REPAIR

PERIOD (MONTHS)

Phonak RemoteControl Phonak 076-0065-P5 V5286 $210.00 25.000% $157.50 $110.00 12 12

N/A

Partner Mic Phonak 076-4001-P511 V5286 $399.00 25.000% $299.25 $110.00 12 12

N/A

DECT II cordless Home Phone Phonak 076-0050-P511 V5286 $229.00 25.000% $171.75 $110.00 12 12

N/A

PilotOne II Phonak 076-0019-P5 V5286 $209.00 25.000% $129.35 $110.00 12 12

N/A

RemoteMic II Phonak 076-0039-P509 V5286 $105.00 25.000% $78.75 $110.00 12 12

N/A

ComPilot II (includes power supply)Phonak

076-0023-P520V5286 $259.00 40.060% $194.25 $110.00 12 12

N/A

ComPilot AIR II (includes power supply) Phonak 076-0028-P520 V5286 $299.00 25.000% $224.25 $110.00 12 12

N/A

TV Link II Phonak 076-0040-P520 V5286 $199.00 25.000% $149.25 $110.00 12 12

N/A

Connects Venture hearing aids wirelessly to cell phones

and Bluetooth-enabled music sources

Connects Venture hearing aids wirelessly to cell phones

and Bluetooth-enabled music sources without a neckloop

The interface to TV and other audio sources supporting

digital audio signals

Cordless home phone transmits calls directly and

binaurally to all wireless Phonak hearing instruments -

Venture Compatible

Remote compatibility-Marvel hearing aids

Remote microphone-Marvel hearing aids

Remote compatibility-Venture hearing aids

Wireless microphone for one-on-one conversations over

distance.

Exhibit A - Sonova Phonak - Contract No. 129975 Amendment No. 4 25 of 25